Manager of Clinical Quality and G&A Review

Responsible for overseeing the day-to-day operations of the clinical appeal review process, and performing activities that evaluate and improve the quality and safety of care and services. This individual will also assist in the design and implementation of quality improvement initiatives in support of the strategic objectives of the organization.

Responsibilities

• Responsible for the operational execution of clinical quality management (QM) activities and appeal day-to-day operations; guides Clinical QM/G&A units to meet and exceed department quality, compliance, timeliness, and production goals.
• Provides overall clinical leadership and governance for the Grievance & Appeals (G&A) Department, ensuring all clinical reviews are conducted in accordance with regulatory standards and organizational policies ensuring consistent application of plan policies and contractual requirements.
• Oversees monitoring and reporting as required by regulation or contract; identifies provider trends discovered through PQI, PQR, and G&A case review.
• Analyzes clinical trends and outcomes to identify emerging risks, assesses potential quality concerns, and uncovers opportunities for process improvement, while driving strategic initiatives across internal teams and cross-functional partners.
• Identifies potential quality risks or opportunities for process improvement and implements appropriate courses of action.
• Serves as clinical subject matter expert, providing guidance to internal stakeholders and collaborating cross-functionally to deliver processes, procedures, and systemic training opportunities and efficiencies to support QM and appeal team members.
• Develops policies and procedures (P&Ps), workflows, and required documents to meet federal and state regulatory requirements.
• Oversees health promotion and quality initiatives.
• Acts as educator and resource to departments in matters of health care quality.
• Performs other duties as requested or assigned.

Requirements

• 8+ years of experience with a Bachelor’s degree; 1+ years of supervisory/management experience.
• 2-3 years of experience in Quality Management Review, Denial Management, Case Management, or related experience, including leadership in a clinical operational area.
• Minimum 5 years of experience in health insurance.
• Excellent organizational and time management skills, with the ability to meet strict internal and regulatory deadlines with highly confidential information.
• Ability to establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.
• Excellent written, verbal, and electronic communication skills.
• Strong critical thinking, problem-solving, and decision-making/resolution skills.
• Excellent team building, training, and leadership skills.
• Intermediate knowledge of Microsoft Office programs including Word, Excel, and Outlook.

Qualifications

• Unrestricted California Dental License (Required).
• Certified Project Management Professional (PMP) - PMI (Preferred).
• Six Sigma Green Belt Certification (Preferred).

Pay

Pay Grade 22. The national base pay range is $93,445.00 - $202,465.00. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities, related experience, education, certifications, and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.

Benefits

• Competitive base and incentive pay.
• 401(k) with robust matching and non-matching contributions.
• Rich medical and pharmacy benefits.
• 100% employer-paid dental and vision benefits.
• Holistic wellbeing program with deep financial incentives.
• Generous paid time off plus 12 paid holidays and your birthday off.
• Career development and tuition reimbursement.
• Recognition program.
• Family support: adoption assistance, fertility treatment, child, elder, and pet care assistance.
• Social responsibility and volunteer opportunities.
• Employee discount program.

About Us

For over 68 years, we have served our communities by increasing access to affordable, quality care. Our network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico, and the Virgin Islands. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company.

We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. We champion an inspirational workplace through our commitment to trust, service, excellence, and innovation.