Associate Dental Director, Government Programs Dental Consulting and Utilization Management

## Associate Dental Director, Government Programs Dental Consulting and Utilization Management Apply:
This is a hybrid position, both in-office and remote.:
Okemos, MI:
Detroit, MI:
Full time:
Posted Yesterday:
JR101502
*
* Job Title:

** Associate Dental Director, Government Programs Dental Consulting and Utilization Management
** Number of Positions:
** 1
*
* Location:

** Okemos, MI
** Location Specifics:
** Hybrid Position
*
* Job Summary:

** 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. 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:

** Manages assigned clinical staff and supports utilization management operations for assigned government programs business. 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 to support prior authorizations, reconsiderations, appeals, grievances, quality-of-care reviews, peer-to-peer reviews, and state fair hearings.  
** Primary

Job Responsibilities
*** Performs claims adjudication and processing in compliance with applicable federal and state statutes and regulations, code sets, DDPA and DDMI claim processing policies, timely claim adjudication requirements, provider agreements, client contracts, and applicable NCQA and/or URAC accreditation standards.
* Assigns and adjusts clinical worklists and daily priorities to meet turnaround times, balance workload, and address changing operational needs.
* Monitors productivity, quality, turnaround times, calibration, interrater reliability, and adherence to established clinical criteria and procedures; identifies trends and recommends corrective actions.
* Coordinates the application of client, state, regulatory, accreditation, and departmental requirements within assigned operations and escalates policy, compliance, resource, risk, and systemic concerns through established channels.
* Provides 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 in accordance with established requirements.
* Provides subject matter expertise for clinical system requirements, testing, and process improvements related to claims adjudication and grievance and appeals software; coordinates implementation activities within the dental consulting team.
* Maintains training materials, standard operating procedures, and desk-level guidance; delivers onboarding, training, calibration, and ongoing development for assigned clinical staff.
* Participates in clinical and operational meetings with customers and state partners for assigned utilization management operations and coordinates follow-up actions with the dental consulting team.
* Supports provider and claim audits and coordinates referrals to Focus Review involving billing anomalies and fraud, waste, and abuse monitoring; assigns approved follow-up actions to the assigned team.
* Participates in assigned customer, state-partner, utilization…