Sr. Clinical Dental Advisor, DentaQuest

Sr. Clinical Dental Advisor

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

The Sr. Clinical Dental Advisor acts as the primary professional authority on service authorizations and medical necessity determinations. This role ensures that dental services requested by providers comply with state and federal Medicaid regulations, evidence-based standards and dental plan policies. The Sr. Clinical Dental Advisor maintains the highest level of productivity and quality in making service authorization decisions.

How you will contribute:

• 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.

What you will bring with you:

• 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.

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We're proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S., we've also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.