Dental Clinical Reviewer

Provides support and subject matter expertise for member clinical dental review activities. Responsible for determining appropriateness and medical necessity of member dental care services - targeting opportunities for quality improvement and satisfaction for members and providers. Participates with senior leadership to establish strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Oversees all aspects of utilization review and quality management activities related to dental care services for members, including appropriateness and medical necessity of dental care services provided.
• Provides oversight for dental quality programs including Healthcare Effectiveness Data and Information Set (HEDIS) and Pay For Performance (P4P).
• Develops and implements clinical utilization processes and algorithms utilized in the authorizatio...