Reviewing Dentist, Tier III
Guardian Life Insurance
POSITION SUMMARY
Provide clinical review of predeterminations, claims, and/or appeals by accurately reviewing radiographs and/or other diagnostic information to determine claim decision in accordance with Guardian clinical guidelines.
Displays technical and functional competence and expertise; holds self and others accountable for performance.
CANDIDATE RESPONSIBILITIES
- Responsible for maintaining a regular clinical review schedule of approximately 20 hours per week, with an expected 24-48-hour turnaround time for items available for clinical review. Minimum standards for production goals and error rates will apply.
- Responsible for maintaining quality work ensuring that review determinations are sound and supported by the diagnostic materials submitted and in accordance with Guardian Clinical Policies. Participation and acceptable performance on a quarterly IRR, Internal Reliability Rating is required.
- Other administrative quality details include correct clinical review determination processing within Guardian systems, adherence to all current Guardian clinical policies with claim review, participation in panel review and credentialing committees as requested, and proficiency in remote communications (Outlook/Skype).
- Support implementation of any new clinical review policy/criteria recommended by Dental Officer, Dental Standards & Quality Management and maintain awareness of continuous updates as pertaining to clinical review.
- Be a change champion and work well with colleagues
REPORTING RELATIONSHIPS
This position reports to the Senior Reviewing Dentist Manager(s)
Qualifications
CANDIDATE QUALIFICATIONS
Functional Skills
- In-depth knowledge of CDT codes, procedures, and dental insurance concepts
- Strong knowledge of Guardian dental clinical policies and guidelines
- Ability to manages multiple workloads with multiple deliverables
- Adapts to changing business priorities and environments
Leadership Behaviors:
- Demonstrates the courage to make difficult decisions and have candid conversations
- Sets and achieves high-performance standards
- Continuously strives to provide superior/professional customer service
- Expresses oneself in an open and honest manner
- Demonstrates self-awareness and embraces feedback
Position Qualifications:
- Graduate of ADA approved dental school
- Minimum 5 years clinical practice
- Licensed dentist in a minimum of one state (Licensure in multiple states, especially TX, CA preferred)
- Strong communication skills
- Strong computer skills with proficiency in Windows-based programs; including, but not limited to Outlook, Skype, Internet Explorer, and Chrome
About Guardian
Guardian has been helping people protect their futures and secure their lives for more than 150 years. Every day, we serve approximately 27 million people through a range of insurance and financial products. As one of the largest mutual insurance companies, we know what matters most: putting the needs of our customers first. Because everyone deserves a Guardian. Learn more about Guardian at guardianlife.com
Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.
Copyright 2020 The Guardian Life Insurance Company of America, New York, NY.
- Primary Location: United States
- Job: Dental Insurance
- Schedule: Full-time
- Shift: Day Job
- Job Type: Standard
- Travel: No