The opportunity:
The Clinical Review Specialist Lead will organize and communicate daily workload assignments to ensure turn-around times are met for all markets. This role will evaluate and document coverage requirements to ensure the system and the Clinical Review Specialists are processing authorization correctly.

How you will contribute:

• Monitor department Windward queues and staff by primarily using the Claim Inventory Report in Windward to assure turnaround times are being met. Maintain daily spreadsheet of inventory to be completed.
• Prioritize and assure compliance with authorization turnaround times and payment deadlines.
• Identify, troubleshoot, research and evaluate issues and trends and communicate them to management.
• Identify areas that require additional training or education and collaborate with clinical trainer to implement a plan of action.
• Attend and participate in new client and/or new business implementation meetings as well as market meetings.
• Present on departmental process and procedures to internal and external customers.
• Facilitate meetings and/or conference calls regarding authorizations or clinical topics with cross functional groups and/or providers.
• Facilitate resolutions to internal and external clinical issues.
• Address quality issues identified during clinical audits with clinical review specialists.
• Complete monthly one on one meetings with each Clinical Review Specialist
• Complete monthly team meetings for direct reports
• Backup Workflow Coordinator role as needed.
• Recommend any policy, procedure, or technical changes required in workflow or in Windward that are required to maintain turnaround times.
• Read, interpret and review x-rays, models and requests for major dental services based on medical necessity, client coverage, provider participation and member eligibility, in accordance with contract language.
• Resolve claim and prior authorization suspends that require UM Review.
• Review, interpret and evaluate requests for orthodontic prior authorizations.
• Ability to review, authorize and calculate payments on orthodontic continuation of care cases.
• Evaluate contract changes and update Clinical Review Specialist documentation to ensure proper clinical choices are made.
• Evaluate contract implementation/changes and verify the system is processing properly.  Document system problems and notify appropriate departments, validate system implementation and /or corrections.
• Make corrections to determinations to ensure accurate and timely mailing of correspondence.
• Update Utilization Management Leadership on complaints and issues from clients, providers and internal staff.
• Conduct round robins for new employees.
• Update Utilization Management Manager on complaints and issues from clients, providers and internal staff.
• Communicate to management ways to improve processes and productivity of company.
• Communicate to team member's supervisor actions that need to be taken to ensure claims standards and department policies are being met.
• Represent company in a professional manner at all times.
• Adhere to company business processes.
• Other duties as assigned.

What you will bring with you:

• Minimum 2 years' experience as a Clinical Review Specialist or equivalent leadership experience.
• High School Diploma or equivalent.
• Minimum of 4 years of dental assisting experience, degree in dental field or other related experience.
• Ability to read and interpret x-rays, dental models, photos, and/or patient charts.
• Great interpersonal skills.
• Ability to work without supervision
   

Salary:  $52,500 - 78,800
At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.