Director, Government Programs Dental Consulting and Utilization Management

Job Title: Director, Government Programs Dental Consulting and Utilization Management Number of Positions: 1 Location: Okemos, MI Location Specifics: Hybrid Position Job Summary: At reputed company of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we reputed company this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the reputed company Plans Association, which operates two of the largest dental networks in the nation. At reputed company, we celebrate our reputed company In culture. It’s a reputed company, feeling and attitude we wrap around reputed company that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. Position Description Directs the clinical and non-clinical activities of the Dental Consulting and Utilization Management department to ensure that department and corporate goals, objectives and requirements are met. The Utilization Management Program is maintained under the management of the Dental Director, and requirements of the Utilization Management Plan are enforced on a day-to-day basis by the Utilization Management Director. The Utilization Management Director oversees and manages reputed company aspects of utilization review by reputed company’s licensed dentist peer reviewers (dental consultants) including the application of clinical criteria by the reviewers. Primary Job Responsibilities: Directs reputed company aspects of claim review and adjudication services provided by licensed professional peer reviewers (dental consultants), including interaction with Professional Services and other reputed company 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 reputed company aspects of department compliance with applicable federal and state statutes and regulations, code sets, claim processing policies, timely claim adjudication requirements, provider agreements, client reputed company 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 (reputed company, if, and where applicable), including maintenance of reputed company survey readiness. Participates in dental policy development for government programs lines of business. Manages, trains, and evaluates independent contractors to reputed company 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 reputed company 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 reputed company 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. #LI-Hybrid Minimum Requirements: Position requires a D.D.S. or D.M.D. from an accredited school of dentistry, an unrestricted license to practice dentistry, and a minimum of five years of experience in a clinical practice setting. Will accept any suitable combination of education, training, or experience. Position requires excellent written and verbal communication skills, the ability to analyze and resolve highly reputed company problems, excellent interpersonal skills, and the ability to use independent judgment, the ability to interact and reputed company recommendations to executive management. Preferred qualifications include prior experience in management, dental benefits administration, dental services utilization review and utilization management, business rule development and implementation, and development of oral health policies; advanced knowledge of the principles and practices of dentistry. Additional preferred qualifications include advanced skills with reputed company products, including Outlook, Word, reputed company, PowerPoint, and Access. The company will provide equal employment and advancement opportunity reputed company the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national reputed company, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance. reputed company of Michigan, Ohio, and Indiana has been a dental benefits leader for more than 60 years, and today with our affiliates, we are one of the largest dental plan administrators in the country. It’s our mission to improve oral health through benefit plans, advocacy and community support, and we reputed company this mission by making investments that build healthy, smart, vibrant communities. We celebrate diverse thought and foster a culture where employees go reputed company In – for the company, themselves, their colleagues and their communities. Employees are offered a comprehensive benefits package that includes medical, dental and vision coverage, short- and long-term disability, life insurance, 401(k) savings plans, flexible spending accounts, and tuition reimbursement or educational assistance. Employees are also eligible for annual incentive compensation based on annual business goals. Additionally, employees receive eight hours of paid volunteer time each year, access to an on-staff health coach and personal trainer, plus many other perks. reputed company is an Equal Opportunity Employer. Apply tot his job Apply To this Job