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.

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 Sr. Clinical Dental Consultant reviews claims based on medical necessity, in accordance with market contracts, evaluate appeals, counsel providers, identify providers with aberrant utilization patterns, provide clinical aid for provider outreach, and act as a clinical SME (or liaison) for internal entities.

How you will contribute:

Authorize or deny claims based on medical necessity and eligibility, in accordance to contract language after clinical review enters claim status into the system.
Evaluate appeals and identify if proper documentation has been obtained to deny claim. Make further recommendations, request additional information, review charts, and make revised or reiterate claim decision.
Reviews authorization requests for anesthesia and rendering judgement on medical necessity.
Review and render conclusions on all orthodontic claims for handicapping malocclusions specific to each Market contract.
Communicate claim review outcome to participating Dentists, plan members, and Health Plans.
Facilitate and give Provider orientations.
Communicate to management ways to improve processes and productivity of company.
Develop a full comprehension of the administration of the dental program, including, but not limited to: benefit and authorization requirements for Plans and/or States, claims payment and the denial process, and a business understanding of ASO and Risk relationships.
Develop knowledge and understanding of state and federal dental regulations, and proactively alert staff of changes that are taking place.
Provide guidance and education in the provider community on the dental program; provide recommendations in managing the dental program efficiently and effectively.
Represent the company in a professional manner for the market, including meetings associated with the provider community.
Proactively seek out opportunities to speak on the benefits of Medicaid and Medicare dental programs.
Identify community opportunities for the company to participate within, including, but not limited to: health fairs, dental screenings, back to school programs, etc.
Develop an understanding of the oral health wellness and outreach programs offered, working closely with Dental Consultants and staff.
Review dental cases to represent the company at fair hearings, as needed.
Establish relationships with dental associations and key stakeholders in the surrounding region, helping to solidify new business in other states.
Adhere to business processes.
Recruit qualified providers for the network.
Other duties as assigned.

What you will bring with you:

Graduate of an accredited Dental School (D.D.S. or D.M.D).
Orthodontic experience a plus
Maintain an unrestricted dental license.
Knowledge of general dentistry.
Efficient PC skills.
Ability to use analytical/presentation tools such as Excel and PowerPoint.
Organizational and time management skills.
Ability to work with a team and independently to complete assigned tasks without supervision.
Ability to make independent determinations on all types of dental claims.
Excellent written and verbal communication skills.
Ability to distinguish between multiple market benefits.
Ability to prioritize and organize multiple tasks.
Ability to remain organized with multiple interruptions.
Networking and Negotiation skills required.
Ability to travel as needed
Required to attend additional training as requested/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: $147,000 - 235,200 annually
Northern region: $157,100 - 251,420 annually

If you are a Colorado or Nevada resident, the salary range for this position is $133,000 - 212,800 annually.
If you are a Connecticut or Maryland resident, the salary range for this position is $139,400 - 223,040 annually
If you are Washington or Rhode Island resident, the salary range for this position is $147,000 - 235,200 annually
If you are a New York resident, the salary range for this position is $157,100 - 251,420 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:

Medical Services

Posting End Date:

21/11/2024