Dental Director, Health Plan - REMOTE

About the role

Provides support and subject matter expertise for member clinical dental review activities. Responsible for determining appropriateness and medical necessity of member dental care services - targeting opportunities for quality improvement and satisfaction for members and providers.

Responsibilities

• Oversees all aspects of utilization review and quality management activities related to dental care services for members, including appropriateness and medical necessity of dental care services provided.
• Participates with senior leadership to establish strategic plans and objectives.
• Contributes to overarching strategy to provide quality and cost-effective member care.
• Oversees dental quality programs including Healthcare Effectiveness Data and Information Set (HEDIS) and Pay For Performance (P4P).
• Develops and implements clinical utilization processes and algorithms utilized in the authorization process including: statistical methodology for use in utilization management, provider profiling analytics, dental policies and procedures and quality improvement activities.
• Partners with provider contracts to secure and maintain a network of dental providers.
• Maintains accountability for consumer/member related decisions for self and network of dental consultants.
• Ensures that the dental care provided meets the standards for acceptable dental care and that dental protocols and rules of conduct for plan personnel are followed.
• Participates in professional and community activities to provide input/demonstrate dental knowledge related to regulatory, professional and community standards, and issues.

Requirements

• At least 7 years of dental practice experience, including 3 years of experience working in a managed care, insurance, or benefits administration setting, or equivalent combination of relevant education and experience.
• Doctor of Medicine in Dentistry (DMD) or Doctor of Dental Surgery (DDS).
• Licence must be active and unrestricted in state of practice.
• Health care management/leadership experience preferred.
• Current clinical knowledge.
• Ability to gather information and coordinate workflows.
• Ability to work independently and within a team environment.
• Effective time-management and organizational skills.
• Critical thinking and listening skills.
• Decision-making and problem-solving skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Qualifications

• Peer review, medical policy/procedure development and provider contracting experience.
• Knowledge of National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), Medicare, Group/Independent Physician Association (IPA), capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines.
• Active dental licensure in Southwest region (AZ, CA, NV, NM, TX).
• Active membership in a recognized professional organization, such as the American Dental Association (ADA) or National Dental Association (NDA).

Skills

Not specified

Benefits

Not specified

Schedule

Not specified

Pay

$129,504 - $215,040 / ANNUAL