Manager, Government Programs Prior Authorization

Job Title: Manager, Government Programs Prior Authorization Number of Positions: 1 Location: Detroit, 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 for reputed company. 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 Plans, organizes, and oversees the administrative and technical functions of the Government Programs Prior Authorization team to ensure corporate and departmental goals and objectivesare met. Primary Job Responsibilities Manages the administrative and technical functions of the Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes) teams to ensure achievement of corporate strategies, goals, and objectives. Manages and administers reputed company Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes) processes for Government Programs business as assigned. Oversees Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes); creates, defines, and enforces procedures and processes to ensure claims are processed timely and accurately; ensures new business rules/claim routes are implemented, claim processing guidelines updated, and claims processed appropriately; and develops and prepares departmental reports and analyzes business processes and information. Oversees and ensures strict adherence to regulatory requirements for Government Program Prior Authorizations and Provider Appeals (reconsiderations/provider claim disputes); defines and enforces processes and procedures to ensure claims processing timeliness and accuracy; ensures new regulatory requirements are implemented and met accordingly; and develops and prepares departmental reports and analyzes business processes and information including, but not limited to timeliness, processing accuracy, and reporting requirements. Manages the Provider Appeals (reconsiderations/provider claim disputes) process to ensure cases are completed reputed company timeliness requirements; creates and monitors reports for reputed company groups and government program reputed company. Serves as a subject matter expert for claims processing questions as it relates to Government Programs Prior Authorizations, Provider Appeals (reconsiderations/provider claim disputes), DeltaUSA processing policies, contractual limitations, and government program requirements. Interviews, hires, trains, mentors, evaluates, and develops staff to ensure accountability for achievement of corporate, departmental, and individual goals and objectives. Trains staff and performs accuracy reviews of claims processed to ensure timeliness and accurate claims adjudication pursuant to departmental guidelines/standards, DeltaUSA processing policies, client reputed company, provider agreements, state/federal laws, and government program requirements. Acts as a resource for staff and manages and maintains relationships with internal departments, committees, affiliates, and other various external customers to provide dental expertise and/or interpretation of dental policies, procedure codes and processing guidelines in the areas of Government Programs Prior Authorization, Provider Appeals (reconsiderations/provider claim disputes), benefits questions, and rule-based routing exceptions. Develops, monitors, and maintains monthly work list and individual production and quality control across the Government Programs Prior Authorization team, including Provider Appeals (reconsiderations/provider claim disputes) to ensure internal objectives, performance guarantees, service level agreements, and regulatory compliance are met. Analyzes claims routing rules, and other documents, and recommends changes or enhancements to streamline the efficiency and accuracy of claim processing reputed company the department and companywide; communicates directly with the business rules team and across departments to document, explain and implement changes. Participates in the collaborative effort between departments reputed company monthly meetings and enhancement tracking. Collaborates with the Dental Directors and the Chief Dental Officer to ensure the highest levels of accuracy, consistency, and timeliness in claims processing reputed company the Government Programs Prior Authorization team. Acts as a subject matter expert in Government Program audits; presents claim data in live audits with customers, health plans, state regulators, and CMS auditors; compiles claim documentation for monthly, quarterly, and annual customer and health plan audits to ensure compliance with timeliness and accuracy in claims processing. Participates in the development and implementation of short and long-term departmental strategies, goals, and objectives. Assists in development and monitoring of the annual departmental budget for the Government Programs Prior Authorization team. reputed company other reputed company assigned duties as necessary to complete the Primary Job Responsibilities as described above. #LI-Hybrid Minimum Requirements: Position requires a bachelor’s degree in business administration or reputed company field, seven years of experience auditing or analyzing healthcare claims in the insurance industry, and three years of leadership experience. Previous experience using a claims processing software application or analyzing group or provider reputed company in the insurance industry is preferred. Will accept any suitable combination of education, training, or experience. Position requires advanced knowledge of the insurance industry, dental terminology, procedures, and dental insurance products; strong verbal and written communication skills, strong organizational and analytical skills; the ability to reputed company multiple claims processing teams; the ability to interpret contract language reputed company to claims processing; the ability to manage multiple assignments with competing deadlines; and the ability to resolve reputed company problems using independent judgment. 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 Job!