The Clinical Documentation Reviewer utilizes clinical expertise of dental procedures and practices to adjudicate prior authorization requests and claims.
- Process and/or adjudicate claims or treatment authorization requests that require professional review; review supporting documentation and adjudicate by applying dental standards.
- Identify when additional information is necessary to make a claim or prior authorization determination and collaborate with internal and external parties to gather information where appropriate.
- Respond to inquiries from internal and/or external stakeholders regarding claim or prior authorization requests.
- Utilize best practices in identification of potential Fraud, Waste, and Abuse (FWA) issues and report any identified issues to the appropriate party for resolution.
- Process requests for re-evaluation.
- May review and analyze documentation related to patient quality-of-care complaints, state hearings, first level appeals, audits, Conlan cases, and maintain logs of resolved grievances as needed.
- Conduct or assist in developing seminars or training programs as needed.
- This list is not all-inclusive and you are expected to perform other duties as requested or assigned
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