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Minimum Qualifications
Possess a current active Dental Hygienist license;Demonstrate an understanding of utilization review processes.
Basic computer skills to include, but not limited to, Microsoft Office Products.
Role Description:
Process dental prior authorization and program exception requests that require technical decisions by researching, analyzing, interpreting and applying program regulations, policies and internal procedures, independently or in concert with consultants.
Make determinations regarding medical necessity, place of service, appropriateness, compensability, and quality of dental services prescribed for and provided to recipients.
Represent the Department at face-to-face and telephone appeal hearings of a regulatory nature by researching and organizing case materials in order to defend the Department's decision.
Respond to inquiries from providers concerning the Prior Authorization program in order to resolve problems.
Educate providers how to properly complete prior authorization forms Electronically Input administrative decisions.
Prepare routine statistical reports.
Attend relevant meetings as necessary to keep abreast of program changes.
Keep relevant personnel informed of daily work flow issues and program needs to ensure efficient program operation.
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