Company :United Concordia DentalJob Description : 

JOB SUMMARY

The Government Business Dental Director serves as the professional dental/clinical authority for the Department of Defense and Veteran’s Affairs Programs, as well as the Centers for Medicare & Medicaid Services. This position will serve as the authority and be responsible for overseeing performance of government business clinical quality assurance, utilization review and management, and coordinating with the special investigations unit on fraudulent provider activity. This position will develop and provide input on provider communications as it relates to clinical and quality initiatives and quality and appropriateness of dentalcare delivery. This position will have authority over the coverage on new dental procedure codes as it relates to government business. This position will work closely with the Government Operations team to refine and enhance claim adjudication processes and resolution of appeals and grievances as necessary. This position will work with the Provider Network Development and Maintenance team to ensure access to care for Government business and meet with providers as necessary to ensure adequate access to dental care for members. This position will work closely with the commercial business Chief Dental Officer and quality assurance team to develop dental policy and quality assurance guidelines in order to ensure consistent practices when appropriate. The position will work closely with the SVP of Government Business and the Government Business team to identify new business opportunities and assist in proposal preparation.

GENERAL OVERVIEW

Oversight/coordination/completion of utilization review activity, grievances, appeal processes, and dental advisor review processes.Development and oversight of Quality Assurance for federal programs in coordination with the Government.Development of dental review policy and criteria, and exclusions and limitations as directed by the Government.Certain clinical aspects of product development, contractual provisions, and professional communicationsProvide clinical expertise, as necessary, in dental policy interpretation/application, and in pre-payment and post payment reviews of submitted claimsProvide guidance to dental advisors, as it relates to applying clinical criteria directed by the Government for claims and pre-determinations.Serve as the clinical liaison with the Defense Health Agency, Dental Treatment Facility Commanders, and Dental Service Points of ContactServe as a liaison to the professional dental community and representing the company with various government agenciesDevelop specific training for providers on the information in the Dental Reference GuideManagement of the TDP/ADDP network Pay for Performance programs.  Review efficacy and make appropriate changes on a yearly basis.Work with the UCCI Chief Dental Officer to provide guidance on clinical initiatives across the company’s commercial and government businessDevelop training program regarding DoD dental readiness classification application for DoD service members.  Identify specific providers that may need remedial guidance and reach out to them for assistance.Assist the Network Development Team with network access mattersPeriodic nationwide travel is also required.

ESSENTIAL RESPONSIBILITIES

Lead and oversee utilization review and quality assurance endeavors. The Government Business Dental Director ensures the provision of proactive patient care that optimizes the dental health of the patient population, while minimizing costs and educating those involved.  This requires coordination of activities with civilian dentists, UCCI personnel, senior management, dental advisors, professional societies and regulatory agencies.  The incumbent must make recommendations in regard to dental policy concerning eligibility and necessity to the Government.  Additionally, the incumbent must provide guidance regarding referrals to specialists, treatment plans, alternate delivery mechanisms, ancillary services and dental health management emerging technologies.The incumbent may be called upon to represent UCCI during legal proceedings subsequent to fraud investigations. The Government Business Dental Director also participates in UCCI quality assurance, utilization review, and related task forces or committees, such as those related to cost of care, pilot dental projects, and procedures subject to abuse, etc.Oversee professional input to dental policy administration and claims adjudication. This position is the dental authority for the government programs and as such is responsible for all clinical aspects of dental policy, pre-payment dental advisor claim adjudication, grievances and appeal processes, clinical professional communications, and related documentation and training. This includes coordination of retrospective review and appeal processes, as well as conferring with peer consultants retained to provide dental counsel, to ensure that subsequent decisions and recommendations are based on an accurate assessment of the medical, clinical, financial, and behavioral factors at hand. Such information in turn provides a foundation for decisions in regard to utilization issues and opportunities related to fraud/misreporting, claims processing protocols, patient education, provider feedback, dental policy, grievance resolution, quality improvement, etc. This may include definition of appropriate action to be taken in dealing with specific claim circumstances, personal review of highly complex or unusual claims or priority inquiries, and provision of professional advice related to new findings and developments in dental practice theory, technology, or materials.Lead critical professional affairs activities on government programs. Most notably, these activities involve responding to inquiries/areas of noncompliance identified; providing RFP input for large or otherwise critical business prospects; providing clinical advice relative to changes to plan benefit designs; and leading or participating in other projects as business needs dictate.Communicate professional concepts to a variety of audiences. The Government Business Dental Director serves as a liaison to the professional dental community, and represents UCCI in industry, governmental, and public relations capacities. This includes, for example, making presentations to professional societies, contributing articles to internal and external journals and publications and communicating professional concepts to lay, professional, and regulatory audiences. Ensure that qualified clinicians are accountable to the organization for decisions affecting members.

ADDITIONAL RESPONSIBILITIES

Perform other duties commensurate with the positionRepresent UCCI on government work groups or committees as appropriateEnsure consistency of national policy and standard language relative to other regions of the United States.Attend conferences, as available, to maintain up-to-date knowledge of emerging technology, findings, trends, etc.

EXPERIENCE

Required

10 years of experience in military dentistry10 years in a leadership positionBachelors degree

Preferred

Masters in Business Administration

LICENSES OR CERTIFICATIONS

DDS or DMD

SKILLS

Exemplary communications, presentation, writing, and humanrelations skills, as well as a familiarity with information systems and PC based spreadsheet and data processing applications.A strong customer service orientation

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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