Avēsis

Processor

• Leverage your dental clinical expertise to review dental x-rays and documentation, assessing medical necessity for prior authorizations.
• Perform initial reviews of medical necessity cases, ensuring they comply with member eligibility and the covered services outlined in each client contract.
• Conduct reviews of prior authorizations by providers, determining cases of recommended treatment in accordance with Avesis UM procedural guidelines.
• Document approval decisions for treatment in accordance with prescribed UM department procedural guidance, and forwards applicable files to the client health plan as required by each contract.
• Maintain effective intradepartmental communications and actively participate in routine departmental meetings.

Utilization Management Clinical Dental Processor

People Operations

• Responsible for the strategic leadership and operational execution of People Operations, Total Rewards, HR compliance, and HR technology governance.
• Oversee HR Operations and HRIS resources and serves as the primary leader responsible for ensuring scalable, compliant, and efficient people processes.
• Partner closely with executive leadership to drive employee experience, operational effectiveness, cost management, and organizational capability.
• Provide leadership and oversight for the organization's people infrastructure, including HR Operations, compensation, benefits, compliance, and HRIS governance.
• Ensure efficient delivery of HR services, maintaining regulatory compliance, optimizing technology and processes, and developing scalable programs that support both employees and business objectives.
• Lead continuous improvement efforts, manage key vendor relationships, develop internal capabilities, and partner across the organization.

Director, People Operations – Total Rewards

Software Engineer

• The EiPaaS Developer role resides within the Operations department and is responsible for overall ownership of the EiPaaS application (Bridgegate) and its environment.
• Ensure the accurate, timely, and compliant processing of 834 electronic files, provider files, and other items processed through the EiPaaS/Bridgegate application, while maintaining enterprise-wide oversight of all Bridgegate workflows.
• Manage end-to-end processing of HIPAA-compliant healthcare EDI transaction sets, including 834 enrollment files and familiarity with 837 claims and 270/271 eligibility transactions.
• Build, configure, and maintain templates for new 834 electronic files as business needs evolve.
• Monitor all EiPaaS/Bridgegate workflows, not limited to 834 transactions.
• Design and implement comprehensive logging, alerting, and monitoring processes to capture EDI transaction logs, metadata, and automated alerts for data processing anomalies.
• Serve as the primary point of contact for all EiPaaS related issues.
• Maintain detailed documentation for templates, workflows, transaction logic, and monitoring controls.

Healthcare EiPaaS Developer

General

• The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process.
• Provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment.
• Responsible for the completion of appeals and grievances from all states.
• Perform reviews of member and provider appeals and grievances for dental and vision waiver services.
• Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions.
• Document rationale clearly and accurately in alignment with organizational and regulatory standards.
• Work closely with clinical teams as well as other internal operational areas to resolve complex cases.
• Communicate outcomes effectively to members and providers.
• Review and complete all provider appeals and grievances within required timeframes.
• Review and complete member appeals and grievances within required timeframes.
• Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances.
• Issue administrative denials appropriately.
• Refer denials based on medical necessity to appropriate clinical staff.
• Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required.
• Participate in training programs to maintain functional expertise.
• Draft formal correspondence such as acknowledgement and resolution notices.

Appeals and Grievances Coordinator

Customer Success Manager

• Answer 40-60 inbound calls, responding to inquiries ranging from routine to moderate complexity.
• Capture member information accurately and update systems with complete and concise data.
• Ensure flexibility, stay organized, and comply with constantly changing programs and business rules.
• Investigate issues that cannot be resolved at the time of initial call.
• Collaborate with internal teams to research and follow up with the Member until a resolution occurs.
• Comfortable working in the healthcare field, with an acute awareness for privacy, confidentiality, HIPAA requirements and professionalism.
• Ability to determine proper issue escalation - joining forces with other internal departments for answers, therefore closing the loop and providing a solution for the Member.

Utilization Management Clinical Dental Processor

Director, People Operations – Total Rewards

Healthcare EiPaaS Developer

Appeals and Grievances Coordinator

Customer Engagement Specialist