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Location:

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Job Summary:

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and 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.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description:

Manages assigned clinical staff and supports utilization management operations for assigned government programs business. Provides advanced clinical and operational guidance, coordinates workload, training, audit consistency, new business readiness, clinical system testing, procedural documentation, and cross-functional issue resolution, and performs complex clinical determinations as needed to support prior authorizations, reconsiderations, appeals, grievances, quality-of-care reviews, peer-to-peer reviews, and state fair hearings.

Primary Job Responsibilities

• Performs claims adjudication and processing in compliance with applicable federal and state statutes and regulations, code sets, DDPA and DDMI claim processing policies, timely claim adjudication requirements, provider agreements, client contracts, and applicable NCQA and/or URAC accreditation standards.
• Assigns and adjusts clinical worklists and daily priorities to meet turnaround times, balance workload, and address changing operational needs.
• Monitors productivity, quality, turnaround times, calibration, interrater reliability, and adherence to established clinical criteria and procedures; identifies trends and recommends corrective actions.
• Coordinates the application of client, state, regulatory, accreditation, and departmental requirements within assigned operations and escalates policy, compliance, resource, risk, and systemic concerns through established channels.
• Provides complex clinical determinations and guidance for claims, prior authorizations, reconsiderations, grievances, appeals, external reviews, state fair hearings, insurance bureau complaints, quality-of-care reviews, and peer-to-peer discussions in accordance with established requirements.
• Provides subject matter expertise for clinical system requirements, testing, and process improvements related to claims adjudication and grievance and appeals software; coordinates implementation activities within the dental consulting team. 
• Maintains training materials, standard operating procedures, and desk-level guidance; delivers onboarding, training, calibration, and ongoing development for assigned clinical staff. 
• Participates in clinical and operational meetings with customers and state partners for assigned utilization management operations and coordinates follow-up actions with the dental consulting team. 
• Supports provider and claim audits and coordinates referrals to Focus Review involving billing anomalies and fraud, waste, and abuse monitoring; assigns approved follow-up actions to the assigned team. 
• Participates in assigned customer, state-partner, utilization management, credentialing/recredentialing, quality assurance, research, and government programs policy and claims processing meetings; coordinates follow-up actions for the assigned team.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a D.D.S. or D.M.D. from an accredited school of dentistry, a current, unrestricted license to practice dentistry, including state-specific licensure in the states as required by the particular state, line of business, or client, and ten years of clinical dental practice experience. Previous Medicaid, Medicare Advantage or dual eligible programs either in clinical practice, dental consulting or state administration, management, dental benefits administration, dental services utilization review and utilization management, business rule development and implementation, and development of oral health policies experience preferred. Will accept any suitable combination of education, training, or experience.

Position requires knowledge of the principles and practices of dentistry; knowledge of dental terminology and procedure codes; the ability to render independent clinical opinions regarding dental conditions, procedures, and treatment; knowledge of dental terminology and procedure codes; the ability to review and interpret radiographs and other clinical documentation; the ability to review and resolve complex clinical and benefit related issues; strong written and verbal communication skills; the ability to analyze and resolve highly complex problems; strong interpersonal skills; and the ability to use independent judgment.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, 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.