You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. Youll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, youll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:

Location: We support US flexible working arrangements in the contiguous 48 states.

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.

The opportunity:
The Clinical Review Specialist provides timely and accurate review and authorization of dental services based on eligibility and contract requirements.

How you will contribute:

Successful completion of the Clinical Review Specialist training program
Read, interpret and evaluate x-rays, models and requests for major dental services based on medical necessity, client coverage, provider participation and member eligibility, in accordance with contract language
Resolve claim and prior authorization suspends that require UM Review
Consistently meet productivity requirements
Maintain audit score of 95% or greater
Pass the IRR quarterly
Communicate and work effectively with co-workers and Team Leads to coordinate workload to ensure all work is completed daily
Knowledge of reference materials and documentation that contain market nuances
Respond to follow-ups
Provide customer service via the telephone to providers regarding clinical issues
Other duties as assigned

What you will bring with you:

High School Diploma or equivalent
1 year dental assisting experience
Previous dental insurance experience a plus
Ability to read and interpret x-rays, dental models, photos, and/or patient charts
Good interpersonal skills
Ability to work without supervision
Excellent oral and written communication skills
Efficient PC skills (Word, Excel, Outlook)
Ability to prioritize and organize multiple tasks
Ability to remain organized with multiple interruptions
Knowledge of telephone systems
Ability to work in excess of 40 hours in a week
Required to attend additional training as required/deemed necessary

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Not ready to apply yet but want to stay in touch? Join our talent community (https://pages.beamery.com/sunlifecareers/page/join-us-canada) to stay connected until the time is right for you!

Life is brighter when you work at Sun Life

Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
A flexible work environment with a friendly, caring, collaborative and inclusive culture
Great Place to Work® Certified in Canada and the U.S.
Named as a “Top 10” employer by the Boston Globes “Top Places to Work” two years running

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

If you are a California resident, the salary range for this position is:

Southern region: $43,900 - 59,300 annually
Northern region: $47,000 - 63,500 annually

If you are a Colorado or Nevada resident, the salary range for this position is $39,700 - 53,600 annually.
If you are a Connecticut or Maryland resident, the salary range for this position is $43,900 - 59,300 annually
If you are Washington or Rhode Island resident, the salary range for this position is $43,900 - 59,300 annually
If you are a New York resident, the salary range for this position is $47,000 - 63,500 annually

We consider various factors in determining actual pay including your skills, qualifications, and experience. In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email recruitingUS@sunlife.com to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

Job Category:

Claims - Health & Dental

Posting End Date:

02/01/2025