Director, Professional Review and Utilization Management
About The Position
The Director, Professional Review and Utilization Management leads dental consultants and oversees clinical reviews, appeals, and policies that support consistent and appropriate benefit decisions. The role manages clinical claims reviews, second-level determinations, appeals, treatment grievances, quality-of-care matters, and investigations of potential fraud, waste, and abuse. It also manages professional review vendors and monitors their performance, quality, and clinical consistency. In partnership with the Vice President, Dental Science & Network Strategy, the Director supports review policies, utilization guidelines, dental policy, quality management, utilization data, and peer review. The position analyzes utilization trends and provider outliers, oversees site reviews and quality audits, and tracks the timeliness, accuracy, and consistency of reviews. The Director also leads planning, budgeting, team development, and performance management, and serves on assigned projects and committees.
Requirements
- DDS or DMD degree.
- State dental license in good standing.
- Expertise in dental benefits, industry trends, utilization review, dental policy, quality assurance, and reimbursement.
- Knowledge of dental science, review standards, data analysis, practice protocols, Current Dental Terminology (CDT), and American Dental Association (ADA) issues.
- Working knowledge of claims processing and clinical and professional review policies.
- Strong written, verbal, and interpersonal communication skills.
- Sound analytical and problem-solving abilities.
- Proficiency in management, budgeting, information systems, and multiple software applications.
- Ability to travel within Illinois and occasionally out of state.
Nice To Haves
- Illinois dental licensure.
- At least 10 years of clinical experience.
- Three years of dental consulting or professional claims review experience.
Responsibilities
- Lead clinical claims reviews, including second-level determinations, in accordance with Delta Dental guidelines.
- Train, coach, and manage dental consultants and promote consistent clinical determinations through standardization exercises.
- Oversee clinical appeals and second-level dentist reviews, including peer-to-peer discussions with treating dentists.
- Resolve quality-of-care and treatment grievances; investigate fraud, waste, and abuse and recommend resolutions to the Vice President, Dental Science & Network Strategy.
- Assess treatment necessity and appropriateness, answer policy inquiries, and guide Professional Relations, Claims, and Customer Service on escalated clinical matters.
- Manage professional review vendors and monitor performance, quality, and clinical consistency.
- Partner with the Vice President, Dental Science & Network Strategy on review policies and utilization guidelines, and support dental policy, quality management, utilization data, and peer review.
- Analyze utilization trends and outlier provider patterns; oversee site reviews and quality audits; track review timeliness, accuracy, and consistency.
- Lead planning, budgeting, team development, and performance management.
- Serve on assigned projects and fraud, quality, and peer review committees.
Benefits
- Free dental coverage for employees and their dependents.
- Free vision, life, and short- and long-term disability coverage.
- Medical plan options.
- 401(k) with company match.
- Generous paid time off.
- 11 paid holidays per calendar year.
- Collaborative culture and healthy work-life balance.
- Hybrid work schedule.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
Ph.D. or professional degree
