Referral Specialist at Avesis in Sacramento, California

Job Description:

Avēsis is a rapidly growing eye care, dental and hearing company serving approximately 8.5 million members for both commercial and government programs. The Referral Specialist Coordinator is responsible for processing Dental Specialty Referrals received from providers and health plan members in accordance with policies, procedures, and guidelines as outlined in Avesis contractual agreements. Specialty referrals are processed using Avesis systems and on-line reference resources that specify the details and scope of benefits. The processors productive output is guided by performance objectives that specify the volume of referrals to be processed on an hourly basis. Must be able to meet accuracy, quality, and productivity standards as determined by Avesis.

Essential Job Functions

• Understand Avesis’ contracts and performance requirements for specialty referral workflow and processing according to procedural guidelines.


• Conducting reviews of referral requests by provider to authorize the recommended treatment, in accordance with Avesis UM procedural guidelines, or to refer  the case to a Dental Director or consultant for professional clinical review.        


• Resolving escalated referrals through research and tracking and trending of issues to improve internal processes.


• Testing and implementation of system changes and updates


• Thorough knowledge of diagnostic and procedural coding for dental claims.


• Skilled use of Avesis systems and applications for referral processing and research of provider, member, and utilization management data.


• Timely and accurate processing of specialty referrals as required in contractual and regulated time frames.


• Apply policies and procedures to confirm that specialty referrals meet the criteria for approval as indicated in contractual guidelines.


• Attendance in team meetings related to referral processing, updates for company policies and procedures, quality assurance findings, and other related communications.


• Ability to meet or exceed quality, accuracy, and production standards as determined by Avesis.


• Other duties as assigned

Requirements

• Dental knowledge and experience preferred


• Associates degree in a related field is preferred; High School Diploma or GED is required


• Knowledge of Medicare, Medicaid, and Commercial insurance


• Knowledge of CDT Dental Procedure Codes


• Strong skills using Microsoft applications and other windows-based tools


• Ability to read, write, and communicate at a professional level


• Ability to manage multiple tasks and prioritize work


• Effective time management and organizational skills


• Ability to work overtime as needed

About Avesis:

Avesis has been providing essential ancillary benefit solutions since 1978. Since its inception Avesis has developed, administered and refined its offerings to provide clients with best-in-class product choices and services. Today, our programs cover more than 8.5 million members throughout the country. We strive for excellence in all that we do and our benchmark performance in terms of member satisfaction and client retention underscores this singular focus.

The continued upward spiral in health care costs has challenged sponsors, providers and payers of health benefits to deliver high quality care in the most cost-effective manner possible. The Avesis benefits menu has been created to meet that challenge by making available quality essential ancillary benefit services at the lowest possible price while never sacrificing the highest quality of service. Providing outstanding customer service is a top priority, and our core values of accountability, empowerment, excellence, and integrity help us achieve high member and client satisfaction.

As of January 2016 Avesis is a wholly-owned, independent subsidiary of The Guardian Life Insurance Company, a distinction that brings even more capabilities to Avesis. The Guardian is a Fortune 250 mutual insurance company that has put its policyholders and clients above all else for more than 150 years, and it has earned them not only a great reputation but awards and accolades from such authorities as J.D. Power. Adhering to high standards, doing the right thing, and making people count are the founding principles that has kept Guardian financially sound and made them one of the largest insurance companies in the country.

In January 2017, Premier Access joined the Avesis family. Premier Access has focused on direct state contracts for Medicaid and Chip, specifically in California and Utah. They were one of the original participants in the Chip and Medicaid programs.  

Avesis is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.