Dental Review Consultant

This is a part time position with an expectation of working 4 hours per week.

The Role

This part time position is responsible for the clinical integrity, accuracy and consistency of our dental service reviews. The consultant evaluates documentation for clinical dental services submitted under various CDT codes to ensure they represent necessary and appropriate care for our members. These reviews can occur as pre-treatment estimates, claim submissions after the services have been completed or as appeals to initial denials.

In performing these duties, the dental consultant will collaborate with cross-functional team members for consultation and advice, ensuring all reviews are conducted thoroughly and in accordance with our established guidelines. Collaboration is performed through various channels including but not limited to emails, phone calls, internal systems and meetings.

Excellent communication skills are essential, as the consultant will also contact submitting providers as needed to clarify documentation or deliver determination notifications.

Your Day to Day

1. A primary responsibility is to evaluate the clinical necessity, appropriateness, and efficacy of dental procedures requested or performed. This involves using a set of formal techniques to review the dental care request and collaboration with others for proper adjudication. The expectation would be the ability to daily review the limited clinical assignments so that adjudications can be made on a timely basis in accordance with regulatory standards.

2. Collaborate with various business areas to offer guidance and solicit input into clinical policies. This collaboration would be primarily with dental utilization reviewers from claim operations and dental network managers from our network contracting division.

3. Interact with dental providers when there is a question about the documentation submitted for claim predetermination or review to assure all necessary information is being considered before adjudication.

5. Represent Dental Blue at professional meetings and maintain active involvement with organized dentistry.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.

We're Looking for:

Strong Clinical Foundation: A robust clinical background in dentistry is essential. This candidate would be a licensed dentist in Massachusetts, preferably with extensive experience in a clinical setting. This practical experience is vital for making credible assessments of the necessity and appropriateness of various dental treatments and procedures.

Keen Analytical and Critical-Thinking Abilities: The position demands strong analytical skills to interpret and apply clinical guidelines to specific cases. A candidate must be proficient in evaluating dental records, treatment plans, and other clinical data to make objective, evidence-based decisions.

Unyielding Ethical Standards: Given the nature of the role, which involves making determinations that impact patient care, a high degree of ethical integrity is necessary. The consultant must be capable of making judgments that are impartial and consistent with our policy of fair reviews.

Exceptional Communication Skills: Effective communication skills are important for this role. The consultant will need to interact with dental providers to request additional information or to provide clarification on review decisions. The ability to engage in clear and professional dialogue is essential.

Meticulous Attention to Detail: The review process is detail-oriented and requires a methodical approach. A candidate should be highly organized and thorough to ensure that all relevant information is considered and accurately documented and responded to in a timely manner.

What You Bring:

Education

• Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD):A foundational requirement for this position is a degree from an accredited dental school and a current unrestricted dental license in Massachusetts. This ensures the candidate has the necessary clinical knowledge to understand and evaluate a wide range of dental procedures and treatments.
• State Licensure:The candidate must hold a current, unrestricted license to practice dentistry in Massachusetts. This is a standard requirement for any practicing dentist and demonstrates that they have met the state's requirements for professional practice.

• Clinical Practice:Significant experience in a clinical setting as a practicing dentist is crucial particularly as a general dentist. This hands-on experience provides the practical knowledge needed to assess the appropriateness and necessity of care in real-world situations. A number of years of clinical practice would be expected.
• Utilization Review or Insurance Experience:While not mandatory, prior experience in utilization review, quality assurance, or a similar role within the dental industry would be highly advantageous. This experience would indicate familiarity with the principles of managed care, clinical guidelines, the review process and comparable computer skills applications in Outlook, Word, and Excel.
• Knowledge of Dental Coding and Terminology:A strong understanding of dental coding systems (such as CDT) and terminology is essential for accurately reviewing claims and treatment plans.

In summary, the ideal candidate would be a licensed dentist with substantial clinical experience, and preferably, a background in the dental insurance industry with excellent communication skills.

What You'll Gain:

Supplementation to Clinical Practice

• Work-Life Balance:These positions typically offer a supplementation to your private practice schedule and the ability to use your clinical knowledge from practice in an administrative role to enhance the value of care to our members.
• Reduced Physical Strain: An office/home based review role eliminates or reduces the physical stress often found in clinical dentistry.
• The role provides an opportunity to affect dental care on a much larger scale than is possible when treating individual patients.

• System-Level Influencing ensures that care is delivered to thousands of members in an efficient, effective, and necessary manner.
• Focus on Evidence-Based Dentistry:The position is deeply rooted in the analytical application of the latest clinical guidelines and evidence, which can be educational about the science of dentistry.

• New Skill Acquisition:It allows a clinician to develop valuable new skills in areas like data analysis, health policy, communication, and working within a corporate structure.

In essence, this position appeals to experienced dentists who are looking for a new challenge, a better work-life balance, and a chance to apply their clinical knowledge to improve the healthcare system from a different vantage point.

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.