LIBERTY Dental Plan is committed to building collaborative and innovative teams nationwide. As one of the nation’s fastest-growing dental insurance plans, LIBERTY is expanding and excited for the future.  

This position is Hybrid (Partial Remote / On-Site) from any of our FL offices:

• Tampa, FL
• Sunrise, FL
• Tallahassee, FL

Job Summary:

The Dental Clinical Specialist will primarily be responsible for the Utilization Management and Utilization Review Programs and ensuring the timely oral health decision-making and adjudication of dental claims and prospective requests for dental services (referrals and pre-authorizations) across all lines of business including Commercial, Medicare Advantage and Medicaid programs. They will formulate reviews to Peer-to-Peer requests and conduct Peer-to-Peer calls. The Dental Clinical Specialist will be involved in state oral health programs of LIBERTY, other clinical review activities, Tele-dentistry, and Special Investigation Unit (SIU) activities. They will be an active participant on the National Peer Review, Utilization Management, Credentialing and Quality Management & Quality Improvement Committees.

Essential Duties:

• Participate and/or complete Network Quality Management Program and SIU activities (provider site reviews/consultations, utilization management and utilization review analysis, etc.) and recommend actions to resolve identified provider trends and treatment patterns.
• Conduct Peer-to-Peer calls to discuss utilization trends, quality issues and trends in prospective and retrospective claims submissions.
• Identify potentially unnecessary services in relation to care delivery settings.
• Examine dental charts for focused audits of aberrant utilization and care delivery patterns.
• Occasional on-site chart review for the state provider network.
• Use clinical expertise to make appropriate dental interpretations and decisions, as required.
• Develop and maintain subject matter expertise in LIBERTY dental benefit plans and applicable State Medicaid Programs. As requested, contribute to required regulatory reporting.
• Participate in Quality Improvement and Provider Credentialing Committees and provide input on appropriate resolution of member and/or provider grievances.
• Collect and evaluate data from Grievance, Peer Review, Public Policy, and the Credentialing Sub-Committee on a quarterly basis.
• Participate in enrollee Tele-dentistry visits to provide clinical assessment, evaluations, and recommendations based on dental need.

Education/Experience:

• DDS/DMD Degree required
• Active, unrestricted license or certification to practice dental or related health profession in the U.S.
• Must pass credentialing; no probation or listed sanctions
• 2+ years' experience of training, processing, and policy experience preferred
• 5+ years' experience as a practicing dentist

Specific Skills/Knowledge:

• Experience working with the state Medicaid, Medicare and Commercial Program
• Knowledge of current dental terminology, practices, materials, and generally accepted standards.
• Knowledge of clinical dentistry procedure codes and generally accepted clinical and adjudication guidelines on medical necessity of proposed dental procedures.
• Ability to examine and read dental radiographs and chart records.
• In-depth knowledge of managed care delivery systems, reimbursement mechanisms, quality improvement initiatives, and cost reduction methods.

Sponsorship and Relocation Specifications:

LIBERTY Dental Plan is an Equal Opportunity Employer / VETS / Disabled.

No relocation assistance or sponsorship available at this time.