Delta Dental of Michigan ยท 3 months ago
Director, Government Programs Dental Consulting and Utilization Management
Indianapolis, IN
Full-time
Hybrid
Lead/Staff, Director/Executive
5+ years expDelta Dental of Michigan is one of the largest dental plan administrators in the country, dedicated to improving oral health through benefit plans and community support. The Director of Government Programs Dental Consulting and Utilization Management will oversee the clinical and non-clinical activities of the department, ensuring compliance with regulations and managing utilization review processes.
Health Care
Responsibilities
Directs all aspects of claim review and adjudication services provided by licensed professional peer reviewers (dental consultants), including interaction with Professional Services and other Delta Dental of Michigan staff
Assists in the development, adoption, distribution and updates of clinical criteria, scientific references and professional guidelines to support decision-making by licensed professional peer reviewers
Directs all aspects of department compliance with applicable federal and state statutes and regulations, code sets, claim processing policies, timely claim adjudication requirements, provider agreements, client contracts and accreditation standards
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 (when, if, and where applicable), including maintenance of continuous survey readiness
Participates in dental policy development for government programs lines of business
Manages, trains, and evaluates independent contractors to achieve department and corporate goals and objectives
Communicates and collaborates with business rules development staff to establish and implement appropriate business rules
Participates in the development and monitoring of the annual budget for the Dental Consulting and Utilization Management department
Serves on the Utilization Management Committee, including presenting relevant information, guiding discussion on utilization management issues, and ensuring implementation of committee directives. Also serves on the Quality Assurance and Credentialing/Recredentialing Committees
Maintains compliance with and performs necessary professional claim review and adjudication services (where appropriate according to professional experience and/or training), including daily monitoring and maintenance of all relevant Roosevelt worklists and filters
Assigns appropriate professional peer reviewers to those payer worklists and filters commensurate with their degree, training and/or experience
Evaluates the accuracy of professional peer review determinations from source documentation and develops and implements corrective action plans for any noted exceptions
Provides expert advice, interventions and deliverables for reconsideration requests, client inquiries, inquiries from other dental organizations, requests from other departments and plans, peer-to-peer discussions, peer review cases, appeals, insurance bureau complaints and legal actions
Participates in the development and enforcement of company-wide policies, procedures, guidelines, and standards of operations with other departments and affiliate locations, including dental reference web page content
Directs the hiring process for new professional peer reviewers and utilization management staff to manage workload
Serves on the Quality Assurance and Performance Improvement (QAPI) Committee, supporting the Director of Quality Improvement and Population Health through development and analysis of claims data, subject matter expertise on value-based payment and other provider driven initiatives to increase utilization, and ensuring integration between departments to meet contractual requirements
Qualification
Required
Position requires a D.D.S. or D.M.D. from an accredited school of dentistry
An unrestricted license to practice dentistry
A minimum of five years of experience in a clinical practice setting
Excellent written and verbal communication skills
The ability to analyze and resolve highly complex problems
Excellent interpersonal skills
The ability to use independent judgment
The ability to interact and make recommendations to executive management
Preferred
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
Company
Delta Dental of Michigan
Delta Dental of Michigan, with its affiliates in Arkansas, Indiana, Kentucky, New Mexico, North Carolina, Ohio and Tennessee
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Jed Jacobson
Chief Science Officer/Senior Vice President
Andrew Woodard
Vice President, Chief Information Security Officer
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