Director – Government Programs Dental Consulting and Utilization Management
| Company | Delta Dental |
|---|---|
| Location | East Lansing, MI, USA |
| Salary | $Not Provided – $Not Provided |
| Type | Full-Time |
| Degrees | MD |
| Experience Level | Senior |
Requirements
- D.D.S. or D.M.D. from an accredited school of dentistry
- Unrestricted license to practice dentistry
- Minimum of five years of experience in a clinical practice setting
- Excellent written and verbal communication skills
- Ability to analyze and resolve highly complex problems
- Excellent interpersonal skills
- Ability to use independent judgment
- Ability to interact and make recommendations to executive management
Responsibilities
- Directs all aspects of claim review and adjudication services provided by licensed professional peer reviewers (dental consultants)
- Assists in the development, adoption, distribution and updates of clinical criteria, scientific references and professional guidelines
- Directs all aspects of department compliance with applicable federal and state statutes and regulations
- Develops, implements, and enforces the requirements of the Utilization Management Plan
- Directs daily, monthly, and annual activities to ensure compliance with applicable NCQA, URAC and other accreditations standards
- Participates in dental policy development for government programs lines of business
- Manages, trains, and evaluates independent contractors
- Communicates and collaborates with business rules development staff
- Participates in the development and monitoring of the annual budget for the department
- Serves on the Utilization Management Committee and other committees
- Maintains compliance with and performs necessary professional claim review and adjudication services
- Assigns appropriate professional peer reviewers to payer worklists and filters
- Evaluates the accuracy of professional peer review determinations and develops corrective action plans
- Provides expert advice for reconsideration requests and client inquiries
- Participates in the development and enforcement of company-wide policies and procedures
- Directs the hiring process for new professional peer reviewers and utilization management staff
- Serves on the Quality Assurance and Performance Improvement (QAPI) Committee
Preferred Qualifications
- Prior experience in management
- Dental benefits administration
- Dental services utilization review and utilization management
- Business rule development and implementation
- Development of oral health policies
- Advanced knowledge of the principles and practices of dentistry
- Advanced skills with Microsoft products, including Outlook, Word, Excel, PowerPoint, and Access