Associate Dental Director, Government Programs Dental Consulting and Utilization Management

Delta Dental of Michigan•Detroit, MI

24d•Hybrid

About The Position

The Associate Dental Director manages assigned clinical staff and supports utilization management operations for assigned government programs. 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; and performs complex clinical determinations as needed. These determinations support prior authorizations, reconsiderations, appeals, grievances, quality-of-care reviews, peer-to-peer reviews, and state fair hearings. The position applies applicable federal and state requirements, claim-processing policies, client contracts, timely-adjudication requirements, and relevant accreditation standards. It monitors staff productivity, quality, turnaround times, calibration, and adherence to clinical criteria; maintains training and procedural materials; participates in customer and state-partner meetings; and supports provider and claim audits, including referrals involving billing anomalies and fraud, waste, and abuse monitoring. The role is based in Okemos, Michigan, in a hybrid work arrangement. The position requires a D.D.S. or D.M.D. from an accredited school of dentistry, a current unrestricted dental license (including state-specific licensure as required), and ten years of clinical dental practice experience. The company will provide equal employment and advancement opportunity without regard to protected status.

Requirements

D.D.S. or D.M.D. from an accredited school of dentistry.
Current, unrestricted license to practice dentistry, including state-specific licensure where 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 and ability to use independent judgment.
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

Manage assigned clinical staff and support utilization management operations for assigned government programs.
Perform claims adjudication and processing in compliance with applicable statutes, regulations, code sets, company and association policies, timely-adjudication requirements, provider agreements, client contracts, and applicable NCQA and/or URAC standards.
Assign and adjust clinical worklists and daily priorities to meet turnaround times, balance workload, 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 client, state, regulatory, accreditation, and departmental requirements within assigned operations, and escalate 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 on clinical system requirements, testing, and process improvements for claims adjudication and grievance and appeals software; coordinate implementation 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; 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 and recredentialing, quality assurance, research, and government-program 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.