Note: The job is a remote job and is open to candidates in USA. Sun Life is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. The Sr. Clinical Dental Advisor acts as the primary professional authority on service authorizations and medical necessity determinations, ensuring compliance with regulations and standards while maintaining productivity and quality.
Responsibilities
- Prior Authorization (PA) review and authorization: Evaluate dental requests (including x-rays and clinical notes) for appropriateness, completeness, and adherence to Oregon Administrative Rules (OARs); make service authorization decisions
- Specialty Referral Review: Evaluate requests from General Dentists for specialty services (e.g. endodontics, oral surgery) to confirm the clinical basis and compliance with dental plan benefits. Act as a “scope of practice” auditor to prevent unnecessary specialist referrals for procedures the referring General Dentist is contractually or professionally capable of performing, thereby managing utilization costs and member access
- Medical Necessity Determination: Use professional judgment and evidence-based criteria to approve or deny service requests
- Provider Consultation: Communicate directly with dental providers to clarify documentation or provide clinical justification for treatment alternatives
- Represent dental plan in administrative hearings as expert witness
- Participate in the dental plan Peer Review and Credentialing committee
- Expert in specific market nuances
- Consistently exceed productivity requirements
- Identify areas for process improvements within the department
- Other duties as assigned
Skills
- Must hold a DDS or DMD degree with an active Oregon dental license and extensive clinical experience
- Deep understanding of Oregon Administrative Rules (OARs) and CDT coding systems
- Ability to interpret complex clinical data and radiological evidence to make defensible authorization decisions
- Strong interpersonal skills
- Ability to work independently
- Excellent oral and written communication skills for writing technical correspondence and testifying in hearings
- Ability to prioritize and organize multiple tasks
- Ability to remain organized with multiple interruptions
- Required to attend additional training as requested/deemed necessary
Benefits
- Generous vacation and sick time
- Market-leading paid family, parental and adoption leave
- Medical coverage
- Company paid life and AD&D insurance
- Disability programs
- A partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment that supports career growth
Company Overview