Job Title:

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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:

Reviews dental claims and related clinical information to determine medical necessity, appropriateness of care, and benefit eligibility and performs clinical determinations supporting prior authorizations, reconsiderations, appeals, grievances, quality of care reviews, peer-to-peer reviews, and state fair hearings for assigned government programs business.

Primary Job Responsibilities:

• Performs claims adjudication and processing to meet daily turnaround time requirements in accordance with state and client contract obligations.
• Reviews and provides clinical determinations for reconsiderations, grievances, and appeals for Government Programs state and client contract obligations.
• Performs clinical adjudication activities 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.
• Performs or supports provider and claim audits to in collaboration with appropriate Professional Review staff.
• Supports NCQA Utilization Management (UM) and/or URAC UM oversight and quality reporting in the form of regular audits of dental consultant claim determinations and interrater reliability.
• Provides dental expertise and clinical guidance for inquiries from personnel within Professional Review and other departments.
• Provides dental expertise and clinical guidance in support of external review determinations, administrative law and state fair hearings, and insurance bureau complaints, including clinical representation for government programs or client partner as assigned.
• Conducts peer-to-peer conversations with providers in support of utilization management determinations.
• Assists the Dental Director and Director, Government Programs Dental Consulting and Utilization Management with departmental compliance, risk management, and crisis management solutions.
• Participates in Utilization Management, Credentialing/Recredentialing, Quality Assurance, Research, and Government Programs Policy and Claims Processing Committee functions.

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

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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 as required by the particular state, line of business, or client, and five 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.