Director of Clinical Management

Delta Dental of Colorado - Denver, CO (30+ days ago)3.8

Full-time

Delta Dental of Colorado (DDCO) is the state's leading dental benefits company and the only one based in Colorado. Unlike most carriers, we focus on just one thing, dental insurance. We provide our more than 1.2 million members with the convenience of local customer service backed by a national network of dental providers. In addition, we are a non-profit company with a mission to improve oral health in Colorado. Unlike most insurance companies, we are mission-driven, not profit-focused. Our key stakeholders are not just our customers but all the residents in the communities we work and live.

Ninety two percent of all licensed, practicing dental professional in Colorado are a part of our network, giving us the largest, homegrown provider network in the state. Our network helps serve our more than 5,200 unique commercial groups across the state.

With more than 190 employees located in the heart of the Denver Tech Center, you will have a unique opportunity to be a part of a big-company footprint, with a small-company feel

Position Purpose
The Clinical Management Director is responsible for all activities of the Department, overseeing the functions of dental consultants, clinical claims review, and clinical group benefits maintenance, as well as Oral Wellness Program management. The Director will focus on CDT code compliance, maintenance of integration to systems and policy guidelines, and is accountable for accurate use of CDT codes and maintenance for policies, contract and system applications. Clinical education, both internally to staff and externally to clients, is developed and delivered by the Clinical Management Director and his/her team. Efforts to increase oral and overall wellness through clinical and data-driven outreach programs initiated by DDCO will be overseen by the Director of the department.

Key Responsibilities
Clinical Review and Dental Consultants Oversight

Supervise Clinical Review Specialists and Dental Consultants to ensure consistency and compliance with processing policies, claim review and adjudication including quality auditing to ensure adherence to the processing guidelines.
Continually evaluate the need for clinical documentation to maintain the appropriate level needed for claims processing and dental consultant review.
Continually evaluate focus review providers and claims; work closely with Program Integrity to address issues found and resolution to trends identified, and identify ways to ensure clinical review is effective.
GA/Sales/HXC Oversight

Inserting clinical expertise, oversee analysis and maintenance of the procedure subsystem: analyze new sales opportunities from clinical, administrative and impact perspectives.
Participate in sales discussions in regards to benefit design and alignment with current clinical practices, and review of benefit deviations from DDCO standards.
Ongoing development and auditing of history cross check and other clinically related tables for new and renewing groups.
Work closely with Group Administration to ensure benefits built properly in history cross check and procedure tables optimally utilize automation and process properly within the claim system.
Maintain all pricing rules for group set-up within the claims system, identifying the need for updates or creation of new rules.
Clinical and Claims Education

Develop basic clinical knowledge curriculum and educational materials for use inside DDCO (staff training) and external to the company (clients, providers). Topics include the various disciplines of dentistry, oral health improvement, claims processing policies, all from practice perspectives of the specific audiences.
Deliver seminars both internally through short All Employee Meetings monthly, Lunch and Learn Seminars, Provider Seminars, departmental focused training (by request), new employee orientation, and ad hoc for the clients who indicate interest through Sales & Client Services.
Update materials as appropriate and post internally or prepare for distribution externally with the help of Marketing.
Oral Wellness Program Management

Develop and execute action plans and educational materials for use inside DDCO (staff training) and external to the company (clients, providers) that support the end goals of various programs, e.g., oral wellness road mapping, screening for systemic disease in the dental office, integrating dental and medical care, determining overall ROI for dental-medical integration projects for client groups.
Deliver presentations to all stakeholders in the programs developed, both internally and externally.
Work with Marketing to create collateral for distribution to all stakeholders involved in the programs.
General Director Duties

Manage day-to-day department personnel functions related to CDT code and systems applications to achieve department objectives.
Implement business process improvements to streamline and increase corporation and department efficiencies.
Perform data analysis as necessary to determine various claims system issues and implements solutions.
Continually update the claim system and tables for new policies, procedure codes and fees. Communicate the updates to both internal and external stakeholders when appropriate.
Work closely with the Director of Network Management to provide input for creation and maintenance of provider communications, including online newsletter, provider handbook, and dentist section of the web site related to clinical areas.
Work closely with Director of Financial Planning and Analysis to plan, analyze, and update all provider fee schedules. Maintain and upload of fee schedules into the claims processing system to ensure accurate claims pricing and provider payments.
Support liaison to internal provider-related committees as needed.
Accountable for compliance with DDPA/Delta USA policies and adherence to DDPA Membership Standards for Professional Services.
Qualifications

Requires an active dentist or dental hygiene license in the State of Colorado in good standing, and/or 10 years' experience in the dental administration and clinical fields
Minimum master's degree in health care administration, public health, policy or business with a health care emphasis
Possess expert-level knowledge of dental industry
Demonstrated supervisory and management skills
Solid knowledge of systems and technology
Solid ability to exercise initiative, judgment and decision-making within the scope of authority
Strong analytical, critical thinking and problem solving skills
Expert relationship building and interpersonal skills
Expert customer service and presentation skills
Exceptional written and verbal communication skills with the ability to effectively communicate and interact with all levels of personnel and the general public

Preferred Competences:
Independent and creative thinker
Innovative/problem solver
Project management acumen and experience
Driver personality to get things done
Experience with IT systems and implementations
Strong analytical skills
As an Equal Opportunity & Affirmative Action employer, an applicant with a disability or a disabled veteran has the right to request reasonable accommodation required to apply and be considered for one of our positions. To request accommodations for the purpose of applying for one of our positions, you may contact Delta Dental Human Resources at 303.741.9300.