Utilization Management Reviewer (Dental) - Full-time

About Argus Dental & Vision

Argus Dental & Vision ("Argus") is a privately-held, rapidly growing healthcare insurance company looking for a full-time, energetic new team member. If you desire a career within a company culture that fosters innovation, wants to hear your ideas, seeks and recognizes positive contributions, appreciates dedication and allows you to see the results of your efforts working shoulder-to-shoulder within a positive collegiate and motivated environment then - look no further!

Job summary

Primary role is providing high-level analysis of dental benefit data, clinical data and applying it to operational activities of Argus providers.  The UM Coordinator (Dental) is responsible for managing all dental provider requests for pre-determinations and pre-authorizations.

Summary of essential job functions

• Reviews requests for pre-determinations and pre-certification for coverage and compliance with Argus Dental & Vision, Inc. Clinical Guidelines and Provider Manual.


• Evaluates requests for completeness and communicate with providers or with Support Specialist to obtain additional information if necessary.


• Reviews requests to make sure the requested services fall within the individual member’s benefit coverage and limitations.


• Reviews requests to make sure the requested services fall within the Clinical Guidelines/provider manual, and only approves services for which there is specific criteria.


• Consults with medical director regarding cases that fall outside the parameters in the clinical guidelines/provider manual.


• Communicates positive determinations/authorizations to requesting providers.  Communicates negative determinations/authorizations to health plan staff according to denial protocols required by health plan/CMS.


• Works with health plan staff to coordinate services not covered under our contracts with the health plans that may need specialty oversight even though the health plan is responsible for reimbursement.


• Coordinates out of network referrals which may include initial contact, fee negotiation, and provider education.  Consults and collaborates with provider network management team to arrange single case agreements where necessary.


• Coordinates second opinions at member’s request.

Minimum requirements

• Microsoft Office Suite Tools


• Ability to learn customized software systems


• Ability to facilitate relationships with health plan partners, to coordinate member care.


• Ability to facilitate relationships with Argus providers, and along with Provider Network Management team, communicate, educate and assist providers in efficiently processing the necessary paperwork to obtain approval for medically necessary care.

Abilities required

Candidates for consideration will have either a certification as a dental  technician with extensive (5+ years) practice-level experience.  Former UM experience is also valuable to the success of this position.  Should have extensive knowledge of specialty language, practice patterns and acronyms.  Must be able to triage and know when cases are urgent or emergent, based on the information provided on documentation.  Must be able to understand benefit descriptions to assess coverage. Excellent written and telephonic skills to communicate in a friendly, professional manner with providers, health plan staff and other team members.

Argus Dental & Vision maintains a drug-free workplace and performs pre-employment substance abuse testing.