Review, analyze, and process complaints and appeals regarding dental services. This position communicates with both internal and external entities to resolve complex payment disputes, quality of care issues, and requests for appeal regarding the denial of healthcare and/or dental services.Analyze, research, and process appeal requests from members and providers regarding denied requests for clinical services and/or payment. Analyze, research, and resolve complaints and grievances filed by members or providers regarding unsatisfactory aspects of dental and/or vision benefit provisions or care.Communicate effectively with clients, members, and providers in the investigation and resolution of various appeals, complaints, and grievances.Document all appeal, complaint, and grievance activity for reporting and trending analysis.Create formal correspondence to confirm receipt and provide resolution for member and provider complaints and appeal requests.Open, analyze, and process all inbound mail and email communication to the Appeals department.Review and process requests for continuation of orthodontic care.Maintain strict compliance and regulatory standards for appeal and grievance turnaround times and documentation requirements.Utilize resources available to maintain current knowledge and understanding of dental plans and coverage provided.

Review x-rays, patient charts, and other patient records to ensure the treatment/service provided falls within the insurance plan guidelines and that the service was appropriate for the condition. Review pre-authorization paperwork to ensure the intended treatment meets the dental plan criteria and relevant program criteria.Enter new authorization schedules, guidelines and denial reasons into company systems to ensure successful implementation of new clients.Maintain accurate and detailed notes of work performed in the company system. Respond to questions from internal and external customers in a thorough and timely manner utilizing communication that is easily understood by others. Utilize resources available to assess issues (set up, system, etc.) and locate appropriate resolution.Utilize resources available to maintain current knowledge and understanding of dental plans and coverage provided.Contact provider offices to obtain additional information as needed.Additional Responsibilities: Identify trends related to provider over or under utilization of dental services and refer on to internal resources for appropriate research and resolution.Provide education and training to new and current dental consultants regarding system capabilities and requirements. Ensure consultants have all necessary resources (i.e. client contract, etc.) to complete the job. Act as liaison for department during implementation of new clients by attending cross functional meetings, understanding deliverables for department, communicating appropriately to team members, and ensuring completion of deliverables timely and accurate

Assisting the dentist during a variety of general/cosmetic dental proceduresTaking and developing dental radiographs (x-rays)Obtaining the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and Sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)

Assisting the dentist during a variety of general/cosmetic dental proceduresTaking and developing dental radiographs (x-rays)Asking about the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)

Assisting the dentist during a variety of general/cosmetic dental proceduresTaking and developing dental radiographs (x-rays)Obtaining the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresHelping to provide direct patient care in dental specialties, including oral surgery and prosthodonticsTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)

Assisting the dentist during a variety of general/cosmetic dental proceduresHelping to provide direct patient care in all dental specialties, including endodontics, periodontics and oral surgeryTaking and developing dental radiographs (x-rays)Asking about the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)

Assisting the dentist during a variety of general/cosmetic dental proceduresHelping to provide direct patient care in all dental specialties, including endodontics and oral surgery including placement of dental implantsMonitoring patient vitals while under conscious sedationTaking and developing dental radiographs (x-rays)Asking about the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)Communicating with patients and suppliers (e.g., scheduling appointments, answering the telephone and ordering supplies)

Assisting the dentist during a variety of general/cosmetic dental proceduresHelping to provide direct patient care in all dental specialties, including endodontics, periodontics and oral surgeryTaking and developing dental radiographs (x-rays)Asking about the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)

Assisting the dentist during a variety of general/cosmetic dental proceduresHelping to provide direct patient care in all dental specialties, including oral surgeryTaking and developing dental radiographs (x-rays)Asking about the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)

Assisting the dentist during a variety of treatment proceduresHelping to provide direct patient care in all dental specialties, including orthodontics, periodontics and oral surgeryTaking and developing dental radiographs (x-rays)Obtaining the patient's medical history and taking blood pressure and pulseServing as an infection control officer, developing infection control protocol and preparing and sterilizing instruments and equipmentHelping patients feel comfortable before, during and after dental treatmentProviding patients with instructions for oral care following surgery or other dental treatment proceduresTeaching patients appropriate oral hygiene strategies to maintain oral health;(e.g., tooth brushing, flossing and nutritional counseling)Taking impressions of patients' teeth for study casts (models of teeth)