Manager, Government Programs Professional Review

Delta Dental Plan of Michigan•Detroit, MI

2d•Hybrid

About The Position

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities for all. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation. At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. Position Description Plans, organizes, and oversees the administrative and technical functions of the Government Programs Professional Review team to ensure corporate and departmental goals and objectives are met.

Requirements

Position requires a bachelor’s degree in business administration or related field, seven years of experience auditing or analyzing dental claims in the insurance industry, and three years of leadership experience.
Position requires advanced knowledge of the insurance industry, dental terminology, procedures, and dental insurance products; strong verbal and written communication skills, strong organizational and analytical skills; the ability to lead multiple claims processing teams; the ability to interpret contract language related to claims processing; the ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment.

Nice To Haves

Previous experience using a claims processing software application or analyzing group or provider contracts in the insurance industry is preferred.
Will accept any suitable combination of education, training, or experience.

Responsibilities

Manages the administrative and technical functions of the Government Programs Professional Review, Prior Authorizations (PA), Pre-Service Organization Determination (PSOD), and Provider Appeals (reconsiderations/provider claim disputes) teams to ensure achievement of corporate strategies, goals, and objectives.
Manages and administers all Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes) processes for Government Programs business as assigned.
Oversees Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes); creates, defines, and enforces procedures and processes to ensure claims are processed timely and accurately; ensures new business rules/claim routes are implemented, claim processing guidelines updated, and claims processed appropriately; and develops and prepares departmental reports and analyzes business processes and information.
Oversees and ensures strict adherence to regulatory requirements for Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes); defines and enforces processes and procedures to ensure claims processing timeliness and accuracy; ensures new regulatory requirements are implemented and met accordingly; and develops and prepares departmental reports and analyzes business processes and information including, but not limited to timeliness, processing accuracy, and reporting requirements.
Manages the Provider Appeals (reconsiderations/provider claim disputes) process to ensure cases are completed within timeliness requirements; creates and monitors reports for priority groups and government program oversight.
Serves as a subject matter expert for claims processing questions as it relates to Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes), DeltaUSA processing policies, contractual limitations, and government program requirements.
Interviews, hires, trains, mentors, evaluates, and develops staff to ensure accountability for achievement of corporate, departmental, and individual goals and objectives.
Trains staff and performs accuracy reviews of claims processed to ensure timeliness and accurate claims adjudication pursuant to departmental guidelines/standards, DeltaUSA processing policies, client contracts, provider agreements, state/federal laws, and government program requirements.
Acts as a resource for staff and manages and maintains relationships with internal departments, committees, affiliates, and other various external customers to provide dental expertise and/or interpretation of dental policies, procedure codes and processing guidelines in the areas of Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes), benefits questions, and rule-based routing exceptions.
Develops, monitors, and maintains monthly worklist and individual production and quality control across the Government Programs Professional Review, PA, PSOD, and Provider Appeals (reconsiderations/provider claim disputes) teams to ensure internal objectives, performance guarantees, service level agreements, and regulatory compliance are met.
Analyzes claims routing rules, and other documents, and recommends changes or enhancements to streamline the efficiency and accuracy of claim processing within the department and companywide; communicates directly with the business rules team and across departments to document, explain and implement changes.
Participates in the collaborative effort between departments via monthly meetings and enhancement tracking.
Collaborates with the Dental Directors and the Chief Dental Officer to ensure the highest levels of accuracy, consistency, and timeliness in claims processing within the Government Programs Prior Authorization team.
Acts as a subject matter expert in Government Program audits; presents claim data in live audits with customers, health plans, state regulators, and CMS auditors; compiles claim documentation for monthly, quarterly, and annual customer and health plan audits to ensure compliance with timeliness and accuracy in claims processing.
Participates in the development and implementation of short and long-term departmental strategies, goals, and objectives.
Assists in development and monitoring of the annual departmental budget for the Government Programs Professional Review team.
Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.