Remote - Director, Managed Care Contracting

Found in: Jooble US O C2 - 2 weeks ago

Wentzville MO, United States Delta Dental of Missouri Full time

Delta Dental of Missouri is seeking a Dental Director in St. The Dental Director is responsible for the areas of Professional Review and Provider Relations, as well as the development and management of the statewide provider networks for Delta Dental of Missouri and its subsidiaries. This position serves as the primary liaison with the dental profession and maintains a positive relationship with these communities. The Dental Director is responsible for coordinating the oral health initiatives related to consumer information resources and the dental profession. This position assists in product development and is responsible for setting, negotiating, and implementing dental policy and procedures consistent with the company’s mission to ensure a competitive position for the company.
The Dental Director advises the company’s Board of Directors, management and employees about recent research and emerging dental science linking oral disease and major systemic conditions, increasing awareness of the importance of oral health research and evidence-based dentistry and their connection to good overall health. This position educates and informs this same group on dental issues and problems that adversely affect the dental profession or the company. This position will serve as the subject matter expert to support the engineering of artificial intelligence regarding claims processing and review strategies. The Dental Director serves as the company’s primary liaison and spokesperson with regulatory bodies and external groups relative to matters requiring dental expertise. This position reports to the Chief Actuarial Officer and its direct reports include all contracted Dental Consultants and the Manager of Professional Relations with the staff in PR.
The Dental Director is responsible for providing leadership and coordination of efforts between departments in the following activities as they relate to Delta Dental of Missouri and its subsidiaries.
• Provider Relations: The position will demonstrate effective communication, negotiations, and professional relations with participating Delta Dental dentists. Educating network dentists and future network dentists (students) about Delta Dental is an important aspect of the position.
• Assists in the development of dental provider networks including recruiting, credentialing, and retention activities for Delta Dental of Missouri and its subsidiaries.
• Spokesperson to the marketplace, the profession, and subscribers on the value of appropriate dental care and treatment.
• Directs provider relations activities including representing Delta Dental with dental professional societies, associations, academic centers, and the national Delta Dental Plans Association.
• Identifies emerging technologies and trends in the dental industry and provides analysis and recommendations to the organization.
• Drives AI-driven automation to streamline dental claim reviews and processing, elevating operational efficiency.
• Responsible for the following relative to Claims Administration:
o The determination of dental necessity and appropriateness of treatment standards. This includes formulating guidelines and implementing staff calibration practices.
o Setting policy for efficient and effective benefit review processes and assuring the compliance of providers and subscribers with the provisions of employer dental contracts.
o Evaluate special claims and benefit review requests in a timely manner. Administer other dental related issues impacted by Delta Dental’s policies or procedures.
o Responsible for the timely and accurate review of claims by dental consultants to achieve cycle-time and accuracy standards.
• Directs Professional Review staff in developing and interpreting consistent processing policies for dental claims.
• This position will provide input and support for the development and improvement/modification of dental products. These products will reflect the best of findings from clinical practice, dental research, and outcomes data.
• Reviews utilization data, dental outcomes, and current dental practices to help determine payment policy. Makes recommendations to the Chief Actuarial Officer, Senior Leadership Team, and the Delta Dental Plans Association on dental policy matters.
• Drives change management to bring innovation to processes, products, and relationships in partnership with others in the organization, in alignment with strategic initiatives.
• Develops, implements, and coordinates processes for professional utilization review, data analysis, credentialing, appeals, fraud and abuse, and quality improvement for Delta Dental.
• Incorporates business intelligence and analytics into recommendations, strategic plans and forecasting.
• Customer Relations: This position shall demonstrate effective communication with existing and potential Delta Dental groups and make presentations as needed.
• Identifies emerging technologies and trends in the dental industry and provides analysis and guidance to the organization in their adoption or rejection.
• Researches and implements market leading dental benefit processing policies in conjunction with peers, to maintain quality assurance and manage utilization.
• Reviews claims and claim determinations, as necessary. Communicates with dental care providers regarding claim and benefit matters to resolve disputes and provide policy decisions.
• Monitors performance and reports variances.
• S. college of dentistry (DMD or DDS) with a current dental license or eligibility for Missouri license to practice dentistry.
• MBA or executive continuing education in leadership, strategy, marketing, branding, operations and/or finance preferred.
• At least four years of dental consulting in the insurance industry preferred.
• Administrative or management experience preferred.
• Familiarity with current dental science, utilization review techniques, data/statistical analysis, practice protocols and ADA issues; ability to analyze data and make effective decisions; knowledge and understanding of healthcare insurance products, and the administrative delivery of group products desirable.
• access to dental care, utilization, dental coverage, value-based payment, dental education, Standards of Practice, payor landscape).
• believes in exceptional patient care, education, research and service to the community.
• General office working conditions which may require sitting for extended periods of time
• Infrequent overnight travel may be required
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The employee is frequently required to use hands and arms to handle, feel and reach as well as operate a personal computer

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