Dental Director, Dental Health Maintenance Organization job at Guardian Life Insurance in TX

Texas State Dental Director DHMO remote type Fully Remote locations Plano/Dallas Area - Regional Office time type Full time job requisition id R000107995 The Dental Director will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. You will ensure that claims, referrals, appeals, and grievances meet state specific regulations, timeframes, and definitions for compliance. You will provide quality oversight and report any quality-of-care issues. In addition, the State Dental Director will be expected to lend support to the entire dental product and to assume responsibility for the functions of utilization management and utilization review, as requested by the Dental Director, Clinical Review. This position will be expected to uphold Guardian’s commitment to ethical business practices. Responsibilities Review & ensure that determination and processing of claims, referrals and appeals meet state regulations, time frames & definitions. Complete adjudication of retail claims timely (queues cleared daily) and communicate issues to the retail team as they arise Complete peer-to-peer calls, educating Providers on Guardian Clinical Policies and clinical determination Complete approximately 10-15hrs/week review of group PPO claims Participate in the development and maintenance of clinical processing policies, for both DHMO and PPO. Ensure regulatory and plan compliance with all established policies and procedures, dental and quality management related regulations, guidelines, processes, regulatory audits, and, associated corrective action(s). Assist in project work by updating any existing guidelines/manuals as needed (e.g. Specialty Referral Guidelines) with guidance from the Quality and Utilization Management Manager. Demonstrate expertise in QMP processes and protocols. Chair Quality Management Committees (as required by state regulations and in compliance with Company policy and procedures) & ensure timely completion and accuracy of the committee minutes: QAC, QIC, Peer Review, Grievance (i.e., Complaint) and Credentialing Committees. Co-chair the credentialing committee. Additional responsibilities: Communicate and work with Sales to provide clinical expertise for presentations and problem resolutions Attend all TX DHMO related meetings as well as the monthly team meeting. Adhere to and meet departmental metrics and performance expectations You have Dental Degree (DDS or DMD) and Dental License for the state of Texas Reside in the state of Texas A minimum of ten years in clinical dental practice MBA MPH or MHA preferred. Dental benefits industry experience is preferred A thorough understanding of the dental insurance industry, claims management experience, and a substantive knowledge of CDT, policy, and procedures Proficiency in Microsoft Word and Excel Excellent written and verbal communication skills Ability to manage multiple projects with multiple deliverables simultaneously Knowledge of, or willingness to learn, regulatory requirements for dental managed care in the State of California You will Continuously strive to provide superior products and customer service Hold self and others accountable for performance Demonstrate self-awareness and embrace feedback Adapt to changing business priorities and environments Reporting Relationships This position reports to the Dental Director, Clinical Review. Location Requirements The primary location for this position is remote with work from home flexibility. Travel to Guardian offices as needed. Salary Range: $96,960.00 - $159,300.00 The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation. Apply tot his job Apply To this Job