Utilization Management Adjustment Clerk

Delta Dental of Missouri is seeking a Utilization Management (UM) Adjustment Clerk in St. Louis, Missouri. The primary role is providing high-level analysis of dental benefits data and clinical data and then applying it to processing procedures and department protocols. The UM Adjustment Clerk will triage all pended claims relevant to utilization management, perform 2nd level reviews, and place restrictions where applicable on denied benefits. This position will coordinate with Professional Relations, Claims, Operations, Customer Service, and CQI departments to provide consistency and ensure compliance with procedures and policies.

Responsibilities

• Process claims selected for utilization review. Manually enter claim information via PC or review previously entered data for accuracy and completeness. Investigate and release all claims including those that suspend for system edits. Make additional payments where necessary. Submit refund requests if overpayment is discovered.

• Process predeterminations selected for utilization review. Manually enter predetermination information via PC or review previously entered data for accuracy and completeness. Investigate and release all claims including those that suspend for system edits.

• Evaluate request for review of claims/predeterminations for completeness of submitted documentation for clinical review and obtains additional information if necessary.

• Review x-rays and clinical documentation to ensure requests fall under clinical guidelines and only approve services which meet specific criteria or refer claim to consultant for decision.

• Write up 2nd re-evaluations with previous documentation, what consultant reviewed and outcome and send to different consultant. If consultant disagrees with services rendered, forward 2nd re-evaluation to Dental Director for final decision.

• Prepare information request letters and/or phone offices for information as needed.

• Position may be assigned to override system pricing logic for certain groups and certain edits.

• Position may be required to access electronic attachment files via internet sites of various vendors.

• Consult with Dental Director regarding cases that fall outside the parameters in the clinical guideline.

• Place restrictions on claims/predeterminations with no benefit conditions per 2nd re-evaluations of two separate consultants or per Dental Director.

• Performing appeals protocols with CQI.

• Process COB claims/predeterminations for consistency with Operations department.

• Perform similar job-related duties as assigned.

Education, Skills, Personal Attributes, and Experience Required

• High School diploma and specialized training in dental codes, procedures, and clinical treatments.

• Knowledge of dental terminology and minimum of 2 years in the clinical dental environment or equivalent work history is required.

• Knowledge of different dental x-rays and reading x-rays for clinical review processing.

• Insurance industry experience preferred.

• Must have thorough knowledge of various transactions and policies utilized in claims administration functions.

• Must have complete understanding of claims processing system functions, screens, and methods to resolve edit.

• Ability to operate calculator and PC keyboard.

• Effective communication skills, both written and verbal, are required due to frequent communication with the public and internal customers.

• Position requires dependable attendance.

• Proven subscription to the company's core values of integrity, trust and respect, innovation, stewardship, excellence, and celebration.

Work Conditions

General office working conditions which may require sitting for extended periods of time

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Specific vision abilities require the ability to focus distant and near objects clearly. While performing the duties of this job, the employee is regularly required to sit, talk and hear. The employee is frequently required to use hands and arms to handle, feel and reach as well as operate a personal computer.