Hybrid Dental Consultant (Clinical Screening and Compliance) at The Computer Merchant, LTD.

Client Dental Consultants apply clinical expertise to review, approve, and/or deny dental treatment authorization requests and claims in accordance with CA Department of Health Care Services (DHCS) Medi-Cal Dental policies.

Your role in our mission

• Manually review of claims, Treatment Authorization Requests (TARs) and related documents for California Medi-Cal members for adjudication, ensuring adherence to Medi-Cal Dental policies and procedures.
• Work within a team of dental consultants, sharing a proportional workload of claims processing and adjudication that have been determined to need professional expertise of an experienced dentist. These claims have been referred from other members of the Claims Processing team, and good communication skills are necessary for continuity within the business operations.
• When needed, dental consultants assist with training and orientation of new dental consultants, providing guidance and mentoring, such as job shadowing and coaching.
• Assist fellow dental consultants with complex cases or claims needing a second opinion, including collaboration for cases involving Medi-Cal Dental Program special needs populations.
• Assist other departments, when requested: a) Claims Processing and Operations, b) Provider and Member Services, c) Grievances/Appeals, d) HR/Onboarding/Interviews, e) Quality Management, f) peer review, and g) referral to/review of findings/adjudication of claims related to Clinical Screening dentist evaluations.

What we're looking for

• A minimum of ten (10) years of prior hands-on, clinical experience as a dentist delivering dental services within a general or recognized dental specialty practice.
• Possession of active (non-expired) license to practice dentistry in CA, which is in good-standing and free of any suspensions or sanctions from Federal, State, or local jurisdictions.
• Minimum of two (2) years working within an organization that provides Medi-Cal Dental services to patients. Prior adjudication and claims processing for the Medi-Cal Dental Program in California is a plus, but not a requirement.
• Demonstrated expertise and knowledge of Medi-Cal Dental criteria and program requirements.
• Position will be required to be On-site (Roseville, CA), with possible Hybrid schedules (Tuesday -Thursday in office).