To facilitate the dental authorization process by evaluating requests, ensuring compliance with medical policies, and coordinating with stakeholders. The role supports decision-making, enhances process efficiency, and contributes to cost-effective, high-quality dental care delivery.
Responsibilities
Core Responsibilities:
Facilitate the dental authorization process by reviewing cases in accordance with clinical guidelines.
Coordinate with healthcare providers to clarify treatment plans and ensure adherence to policies.
Implement authorization decisions based on medical necessity, policy compliance, and cost-effectiveness.
Monitor authorization requests for patterns of overutilization or non-compliance.
Organize case documentation and maintain accurate records of authorization approvals and denials.
Provide clinical insights and recommendations for complex dental cases requiring further evaluation.
Draft reports on authorization trends, key metrics, and performance indicators.
Liaise with internal and external stakeholders to ensure smooth coordination of dental services.
Conduct periodic reviews of provider compliance with dental authorization guidelines.
Participate in audits and investigations related to dental claims and pre-authorization processes.
Receive and address inquiries from providers regarding authorization decisions.
Contribute to continuous improvement initiatives to enhance service quality and efficiency.
Quality & Excellence Management:
Assure compliance with Daman’s medical policies, procedures, and regulatory requirements.
Monitor key performance indicators related to dental authorization and identify areas for improvement.
Participate in quality audits to assess adherence to authorization standards.
Implement corrective actions to resolve issues identified through quality assurance reviews.
Ensure that all authorization decisions are well-documented and justified based on clinical evidence
Qualifications
Preferred Educational Qualifications and Professional Certifications
Bachelor’s Degree inDentistry, Healthcare Management, or a related field.
Master’s Degree inHealthcare Administration, Public Health, or a related field is preferred.
Professional certifications in Dental Healthcare, Medical Insurance, Healthcare Quality, or equivalent are advantageous.
Experience
A minimum of 2-4 years of experience in dental authorization, claims management, or clinical practice in the healthcare insurance sector.
