[Remote] Sr. Clinical Dental Advisor, DentaQuest
Note: The job is a remote job and is open to candidates in USA. Sun Life is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. The Sr. Clinical Dental Advisor acts as the primary professional authority on service authorizations and medical necessity determinations, ensuring compliance with regulations and standards while maintaining productivity and quality.ResponsibilitiesPrior Authorization (PA) review and authorization: Evaluate dental requests (including x-rays and clinical notes) for appropriateness, completeness, and adherence to Oregon Administrative Rules (OARs); make service authorization decisionsSpecialty Referral Review: Evaluate requests from General Dentists for specialty services (e.g. endodontics, oral surgery) to confirm the clinical basis and compliance with dental plan benefits. Act as a “scope of practice” auditor to prevent unnecessary specialist referrals for procedures the referring General Dentist is contractually or professionally capable of performing, thereby managing utilization costs and member accessMedical Necessity Determination: Use professional judgment and evidence-based criteria to approve or deny service requestsProvider Consultation: Communicate directly with dental providers to clarify documentation or provide clinical justification for treatment alternativesRepresent dental plan in administrative hearings as expert witnessParticipate in the dental plan Peer Review and Credentialing committeeExpert in specific market nuancesConsistently exceed productivity requirementsIdentify areas for process improvements within the departmentOther duties as assignedSkillsMust hold a DDS or DMD degree with an active Oregon dental license and extensive clinical experienceDeep understanding of Oregon Administrative Rules (OARs) and CDT coding systemsAbility to interpret complex clinical data and radiological evidence to make defensible authorization decisionsStrong interpersonal skillsAbility to work independentlyExcellent oral and written communication skills for writing technical correspondence and testifying in hearingsAbility to prioritize and organize multiple tasksAbility to remain organized with multiple interruptionsRequired to attend additional training as requested/deemed necessaryBenefitsGenerous vacation and sick timeMarket-leading paid family, parental and adoption leaveMedical coverageCompany paid life and AD&D insuranceDisability programsA partially paid sabbatical program401(k) employer matchStock purchase optionsEmployer-funded retirement accountFlexible, inclusive and collaborative work environment that supports career growthCompany OverviewSun Life is a leading financial services organization dedicated to helping people achieve lifetime financial security and live healthier lives. It was founded in 1865, and is headquartered in Toronto, Ontario, CAN, with a workforce of 10001+ employees. Its website is Apply To this Job
