Prior Authorization Specialist Dental & Medical Crossover Authorizations

Job Summary (List Format) Prior Authorization Specialist (Dental & Medical Crossover Authorizations) 1. Prior Authorization Processing - Submit dental prior authorization requests to commercial and Medicaid payers. - Process medical crossover cases for dental procedures billed under medical insurance. - Attach and review required documentation (radiographs, narratives, clinical records, etc.). - Confirm appropriate code sets (CDT, CPT, ICD-10) before submission. - Track authorization status, payer reference numbers, and next action dates in ClickUp. - Contact payers for status updates or when cases exceed turnaround times. - Record and communicate authorization results and approvals to the practice promptly. 2. Eligibility & Benefits Verification - Verify active dental and medical insurance coverage prior to treatment. - Confirm plan types, effective dates, and coordination of dual coverage. - Review plan benefits, restrictions, and limitations affecting treatment plans. - Identify and communicate coverage issues to practice staff before appointments. 3. Denial Management & Appeals - Analyze authorization denials to determine root causes (missing documentation, coding issues, medical necessity, etc.). - Prepare and submit appeals with supporting clinical documentation as needed. - Follow up on denied or appealed cases within payer timeframes. - Escalate complex or persistent denials to the team lead. - Identify patterns to improve first-pass approval rates. 4. Communication & Reporting - Use HIPAA-compliant ClickUp chat group for all communications with practice staff. - Maintain clear, accurate, and auditable case notes. - Provide daily end-of-shift summaries of case statuses (submitted, approved, pending, follow-up, blocked). - Participate in onboarding and process training calls. - Maintain comprehensive payer-specific notes and authorization process documentation. 5. Required Qualifications - Clinical or allied healthcare degree (Dentistry, Pharmacy, Nursing, Physiotherapy, or similar). - Minimum 1 year of relevant experience (prior authorization, dental/medical insurance, or healthcare revenue cycle with US payers). - Working knowledge of CDT, CPT, and ICD-10 codes. - Understanding of dental-to-medical crossover billing and authorizations. - Solid English communication (written and verbal); experience with payer communications. - Attention to detail in reviewing clinical documentation. - Ability to work independently, manage multiple cases, and meet deadlines. - Willingness to work US Eastern business hours from onsite delivery center. 6. Preferred Qualifications - Experience with dental practice management systems (Dentrix, Eaglesoft, Open Dental, etc.). - Background in academic, hospital-based, or specialty dental practices. - Experience with state Medicaid programs and dental Medicaid authorizations. - Familiarity with oral surgery, sedation, trauma, or sleep appliance authorizations. - Experience using ClickUp or similar task management tools. - Prior exposure to handling denials, appeals, and medical necessity documentation. .