Director, Government Programs Dental Consulting and Utilization Management
At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy, and community support. We amplify 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 Delta Dental Plans Association, which operates two of the largest dental networks in the nation. Our All In culture is a mindset, feeling, and attitude we wrap around everything we do – from taking charge of our careers to helping colleagues and lending a hand in the community.
Primary Job Responsibilities
Direct 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 staff.
Assist in the development, adoption, distribution, and updates of clinical criteria, scientific references, and professional guidelines to support decision‑making by licensed professional peer reviewers.
Direct 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.
Develop, implement, and enforce the requirements of the Utilization Management Plan.
Direct daily, monthly, and annual activities to ensure compliance with applicable NCQA, URAC, and other accreditation standards, including maintenance of continuous survey readiness.
Participate in dental policy development for government programs lines of business.
Manage, train, and evaluate independent contractors to achieve department and corporate goals and objectives.
Communicate and collaborate with business rules development staff to establish and implement appropriate business rules.
Participate in the development and monitoring of the annual budget for the Dental Consulting and Utilization Management department.
Serve on the Utilization Management Committee, presenting relevant information, guiding discussion on utilization management issues, and ensuring implementation of committee directives. Also serve on the Quality Assurance and Credentialing/Recredentialing Committees.
Maintain compliance with and perform necessary professional claim review and adjudication services (where appropriate), including daily monitoring and maintenance of all relevant worklists and filters.
Assign appropriate professional peer reviewers to payer worklists and filters commensurate with their degree, training, and experience.
Evaluate the accuracy of professional peer review determinations from source documentation and develop and implement corrective action plans for any noted exceptions.
Provide expert advice, interventions, and deliverables for reconsideration requests, client inquiries, peer‑to‑peer discussions, peer review cases, appeals, and legal actions.
Participate 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.
Direct the hiring process for new professional peer reviewers and utilization management staff to manage workload.
Serve 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 and other provider‑driven initiatives to increase utilization.
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. The position accepts any suitable combination of education, training, or experience that meets these criteria.
Position requires excellent written and verbal communication skills, the ability to analyze and resolve highly complex problems, excellent interpersonal skills, and the ability to use independent judgment when interacting and making 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 Microsoft products, including Outlook, Word, Excel, PowerPoint, and Access.
We provide equal employment and advancement opportunity within the context of our unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.