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  • 3 weeks ago

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Especialista de Precertificacion Dental




Responsible for overseeing the prospective review of dental services provided to the company beneficiaries and dental clinical audits of the delegated entity. Accountable for precertification interventions to complete the service circle. Ensured the proper use of health resources, well-being, and quality of service provided to insureds.

• Guides insureds and providers on the Precertification process.
• Performs prospective or retrospective procedure reviews, as established by the policy within the established time.
• Reviews and processes the requests that arrive at the department via facsimile, web, and/or mail.
• Communicate with the client, provider, or designated staff to collect the clinical data necessary to conduct the review.
• Documents the information necessary to issue the Precertification in the systems required following established standards.
• Consult and report to the... Dental Consultant cases that do not meet the clinical criteria for the corresponding evaluation according to the established standard.
• Communicates the final determination of the request to the client, provider, or designated clinical staff by mail, telephone, or facsimile, according to departmental rules and procedures and within the established time parameters according to State and Federal law regulations.
• Supports medical staff interventions: modifications, additional request information and follow-ups, notification letter generation, service validations, provider coordination, and letter of agreement referral, among others as needed. Recognizes when to request assistance or direction from leaders.
• Assist the Delegation Oversight unit for dental clinical audits.
• Participates and collaborates in interdisciplinary meetings and departmental quality initiatives.
• Complies fully and consistently with the Company's standards, policies, and procedures and the local and federal laws applicable to our industry, business, and employment practices.
• May perform other duties and responsibilities as assigned, in accordance with the education and experience requirements contained in this document.


Education and Experience: Associate Degree in Dental Assistant and/or Dental Hygienist. At least one (1) year of experience working in Health Insurance Companies.

Certifications/Licenses: Dental Assistant and/or Dental Hygienist License.

Other: Knowledge of Clinical criteria, CPT, and CDT.

Spanish – Intermediate (writing, reading, conversational, and comprehension)
English – Intermediate (writing, reading, conversational, and comprehension)

“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”
San Juan Puerto Rico


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