Company :United Concordia Dental
Job Description :
This job oversees, coordinates and completes the quality assurance and utilization review activity, claim grievance and appeal processes, advisor review processes, credentialing/re-credentialing, dental service delivery, contractual provisions, and professional communications. The incumbent provides clinical expertise, as necessary, in dental policy interpretation/application and in oversight of the Organization's contracted dental vendor(s). Serves as a liaison to the professional dental community and to the various regulatory agencies which oversee the Organization's dental programs in Pennsylvania, particularly Pennsylvania Health Choices (Medicaid).
- Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Oversee utilization review and quality assurance endeavors, both through the Organization's contracted vendor(s) and internal to the Organization. Ensure the provision of proactive patient care that optimizes the dental health of the Pennsylvania Health that optimizes the dental health of the Pennsylvania Health Choices (Medicaid) patient population, while minimizing costs and educating all involved. This requires coordination of activities with dental providers, senior management, dental advisors, dental consultants, professional societies, and regulatory agencies. Oversee management of utilization by educating and making recommendations, when appropriate, in regard to corporate policy concerning eligibility/necessity of various services, referral to specialists, treatment plans, alternate delivery mechanisms, ancillary services, dental health management, emerging technology, etc.
- Provide professional input to dental policy administration and claims adjudication. Dental authority for the assigned region/area, and as such is responsible for all clinical aspects of dental policy, claim adjudication, grievance and appeal processes, professional communications, and related documentation and training. This includes coordination of retrospective review and appeal processes, as well as conferring with peer consultants retained to provide dental counsel, to ensure that subsequent decisions and recommendations are based on an accurate assessment of the medical, clinical, financial, and behavioral factors at hand. Such information in turn provides a foundation for decisions in regard to utilization issues and opportunities related to fraud/misreporting, claims processing protocols, patient education, provider feedback, dental policy, grievance resolution, quality improvement, etc. This may include definition of appropriate action to be taken in dealing with specific claim circumstances (for example, whether radio-graphs or models are necessary), personal review of highly complex or unusual claims or priority inquiries, and provision of professional advice related to new findings and developments in dental practice theory, technology, or materials.
- Participate in/lead critical corporate activities. Most notably, these activities involve responding to inquiries/areas of noncompliance identified as a result of regulatory agency inquiries and audits; providing RFP input for large or otherwise critical business prospects; ensuring adequate network development for new or critical customers; oversight of credentialing processes, inclusive of vendor activity; providing clinical advice relative to changes to plan benefit designs; and leading or participating in other projects as business needs dictate.
- Communicate professional concepts to a variety of audiences. Serve as a liaison to the professional dental community, and represents the Organization in industry, governmental, and public relations capacities. This may include, for example, making presentations to professional societies, contributing articles to internal and external journals and publications and communicating professional concepts to lay, professional, and regulatory audiences. Ensure that qualified clinicians are accountable to the Organization for decisions affecting consumers.
- Perform other duties commensurate with the position. Represent the Organization on National Committees, work groups, etc. Attend national conferences, as available, to maintain up-to-date knowledge of emerging technology, findings, trends, etc.
- Other duties as assigned.
- Doctorate Degree in Dentistry (DDS or DMD)
- 5 - 7 years in the Direct Patient Care Industry
- 3 - 5 years in the Dental Insurance Industry
- 3 - 5 years in Medicaid
LICENSES OR CERTIFICATIONS
- Licensed Dentist (region specific)
Active in the following:
- American Dental Association
- National Association of Dental Consultants
- Academy of General Dentistry
- State Dental Association
- Communication Skills
- Presentation Delivery
- Presentation Development
- Written & Oral Presentation Skills
- Written Communications
- Customer Service
Languages (other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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