Position Purpose: Administer, maintain and implement utilization and quality management activities, which include the review of prior authorizations, clinical appeals and potential quality issues. Provide dental advice and counsel to internal and external customers as needed.
- Responsible for reviewing, administering, and maintaining prior and retrospective authorizations and clinical appeals.
- Resolve grievances related to dental quality of care under the dental plan.
- Actively participates in the functioning of the plan grievance procedures under the dental plan.
- Directs involvement in the implementation of quality improvement activities under the dental plan, including tracking and trending quality care issues.
- Evaluates clinical decisions to ensure they are not influenced by fiscal or administrative management considerations.
- Evaluates dental care provided to ensure meets state clinical criteria and standards for acceptable dental care and ensures dental protocols are followed.
- Assists in the design, development and implementation of appropriate dental policies, protocols and procedures which are in compliance with the most current accepted professional standards
- Actively participates in the functioning of the plan fraud, waste and abuse protocols of the dental plan.
- Responsible for Dental Consultant training and calibration.
- Primary clinical contact for UM, Claims, and Professional Relations personnel.
- Assists in the design, development and implementation of appropriate dental policies, protocols and procedures which are in compliance with the most current accepted professional standards.
Education/Experience: Doctor of Dental Surgery (DDS) or Dental Medicine (DMD) degree from a university-based dental education program accredited by the American Dental Association Commission on Dental Accreditation. 7+ years of clinical dental practice, including 3+ years of experience in insurance or benefits administration setting.