Dental Director Utilization Management Appeals
1 month ago
Job Brief
The Dental Director Utilization Management Appeals, will be responsible for the appeals process of our members in PA, OH and MI. This is a remote role and does require a Pennsylvania license (DMD/DMS).
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
Provide organizational leadership in the operational areas of care management, utilization review, appeals, quality improvement and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management; Corporate Director, Dental Programs; and the Vice President, Utilization Management Physician.
The following responsibilities are in regards to enrollees with medical conditions and their providers:
- Identifying and implementing evidence-based practice guidelines throughout the provider network.
- Overseeing the quality of clinical care for network and non-network providers.
- Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.
- Assuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements.
- Utilizing evidence based standards in making coverage determinations.
Accountabilities
- Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers.
- Serves as dental advisor for all dental appeals.
- Assures that organization dental policies and procedures adhere to contractual obligations.
- Performs clinical case reviews in conjunction with Utilization Management Department.
- Demonstrates knowledge of prescribed and established dental procedures and practices.
- Maintains familiarity with federal, state and local regulations that may pertain to dental operations.
- Provides leadership in the development and implementation of dental policy as it relates to health management.
- Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
- Manages day to day operations and monitors the integration and processing of members to optimize appropriate use of dental health services.
- Participates with Quality Improvement and Population Health in the identification and analysis of dental health information in order to develop interventions to improve clinical effectiveness of medical management strategies.
- Works closely with a multidisciplinary team to ensure dental management and quality management programs are meeting contractual obligations.
- Works with the leadership of the Quality Improvement and Population Health departments to develop competent clinical staff.
- Trains staff on dental issues and provide consultation to staff as appropriate.
- Assists Integrated HealthCare Managers in assessing members’ need for case management services.
- Attends case management meetings and monthly rounds as scheduled.
- Collaborates with the integrated case management team, during scheduled meetings and informally as needed.
- Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures.
- Supports and carries out the ACFC Mission and Values.
- Performs other related duties and projects as assigned.
Education/ Experience:
- DMD/DMS required.
- Must be licensed to practice in the state of Pennsylvania as a DMD/DMS; additional state licensures may be required.
- Must be Board-certified in his/her dental specialty (if a specialty is claimed).
- Must be clear of any sanctions by the applicable state or Office of the Inspector General.
- Must not be prohibited from participating in any Federally or State funded healthcare programs.
- 3+ years in on or a combination of the following:
- Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof
- Full-time medical facility administration or medical facility management experience.
- 3 to 5 years State Management Organization (SMO) experience preferred.
- 5 to 10 years clinical practice experience.
Diversity, Equity, and Inclusion
At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
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