Associate Dental Director, Government Programs Dental Consulting and Utilization Management

Delta Dental Plan of Michigan•Okemos, MI

22d•Hybrid

About The Position

The Associate Dental Director manages assigned clinical staff and supports utilization management operations for assigned government programs business. The role provides advanced clinical and operational guidance, coordinates workload, training, audit consistency, new business readiness, clinical system testing, procedural documentation, and cross-functional issue resolution. It also 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. The position performs claims adjudication and processing in accordance with applicable laws and regulations, code sets, company policies, timely adjudication requirements, provider agreements, client contracts, and applicable NCQA and/or URAC accreditation standards. It coordinates operational requirements, maintains training and procedural materials, participates in meetings with customers and state partners, and supports audits and Focus Review referrals involving billing anomalies and fraud, waste, and abuse monitoring. The role is hybrid and based in Okemos, Michigan.

Requirements

D.D.S. or D.M.D. from an accredited school of dentistry.
Current, unrestricted license to practice dentistry, including state-specific licensure as required by the state, line of business, or client.
Ten years of clinical dental practice experience.
Knowledge of the principles and practices of dentistry.
Knowledge of dental terminology and procedure codes.
Ability to render independent clinical opinions regarding dental conditions, procedures, and treatment.
Ability to review and interpret radiographs and other clinical documentation.
Ability to review and resolve complex clinical and benefit-related issues.
Strong written and verbal communication skills.
Ability to analyze and resolve highly complex problems.
Strong interpersonal skills.
Ability to use independent judgment.
The company will accept any suitable combination of education, training, or experience.

Nice To Haves

Experience with Medicaid, Medicare Advantage, or dual eligible programs in clinical practice, dental consulting, or state administration.
Experience in management, dental benefits administration, dental services utilization review and utilization management, business rule development and implementation, or oral health policy development.

Responsibilities

Perform claims adjudication and processing in compliance with applicable federal and state statutes and regulations, code sets, company claim processing policies, timely adjudication requirements, provider agreements, client contracts, and applicable NCQA and/or URAC accreditation standards.
Assign and adjust clinical worklists and daily priorities to meet turnaround times, balance workloads, and respond to changing operational needs.
Monitor productivity, quality, turnaround times, calibration, interrater reliability, and adherence to clinical criteria and procedures; identify trends and recommend corrective actions.
Coordinate application of client, state, regulatory, accreditation, and departmental requirements, escalating policy, compliance, resource, risk, and systemic concerns through established channels.
Provide 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.
Provide subject matter expertise for clinical system requirements, testing, and process improvements related to claims adjudication and grievance and appeals software; coordinate implementation activities within the dental consulting team.
Maintain training materials, standard operating procedures, and desk-level guidance; deliver onboarding, training, calibration, and ongoing development for assigned clinical staff.
Participate in clinical and operational meetings with customers and state partners for assigned utilization management operations and coordinate follow-up actions with the dental consulting team.
Support provider and claim audits and coordinate referrals to Focus Review involving billing anomalies and fraud, waste, and abuse monitoring; assign approved follow-up actions to the assigned team.
Participate in assigned customer, state-partner, utilization management, credentialing/recredentialing, quality assurance, research, and government programs policy and claims processing meetings; coordinate follow-up actions for the assigned team.
Perform other related assigned duties as necessary to complete the primary job responsibilities.