Clinical Review Support Specialist Ii
CurrentIn my role at DentaQuest, I utilize in-depth dental knowledge and analytical skills to ensure the accuracy and integrity of dental claims, focusing on both government and commercial insurance sectors. My key contributions include:Dental X-ray Analysis: I interpret dental X-rays, applying medical necessity criteria and insurance eligibility, crucial for accurate claim and authorization decisions. This ensures precise service delivery and compliance with health standards.Independent Claims Evaluation: I independently evaluate dental claims, making crucial decisions that impact their approval or denial. This responsibility highlights my ability to handle complex decision-making with precision.Claims Management: I manage updates and reprocess claims and authorizations in the follow-up inquiry queue. This involves a comprehensive understanding of operations across government and commercial units, enhancing operational efficiency and compliance.Quality Assurance: I maintain an audit accuracy rate of 99.7% while processing over 100 authorizations daily, demonstrating my commitment to high-quality service and exceeding regulatory standards.Audit and Compliance Initiatives: I lead audits to identify potential duplicates and expired authorizations, systematically documenting findings in Excel to ensure accountability and reduce waste.Fraud Vigilance: I'm always on the lookout for potential fraud, applying my refined analytical skills to prevent fraudulent activities and safeguard the integrity of our claims processes.AI Technology Enhancement: I participate in testing and improving OverJet AI technology for dental claims. My feedback has driven significant advancements, enhancing the accuracy and efficiency of AI applications in our operations.Through these roles, I actively contribute to organizational goals by advancing technology integration and process improvements, aiming to elevate service delivery and client satisfaction.