Texas State Dental Director DHMO - (19002119)
The Dental Director will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. He/she will ensure that referrals, appeals and grievances meet state specific regulations, timeframes and definitions for compliance. He/She will provide quality oversight and report any quality of care issues directly to the Board of Directors. 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 Chief Dental Officer. This position will be expected to uphold Guardian’s commitment to ethical business practices. It is expected that in this leadership role, the Dental Director will maintain a strong external focus; that includes the customer, the industry, the provider, the patient and the regulators.
Provides dental professional decision making and oversight in the referral/claim and grievance/complaint/appeal processes for Texas DHMO; including the direct adjudication of claims, referrals and grievances.
Oversees quarterly meetings of the Quality Assurance and Peer Review Committees for the Texas DHMO.
Provides leadership and oversight for quality of care standards, protocols, clinical guidelines and Quality Management Program for the Texas DHMO.
Participates in the Dental Credentialing committee ; both PPO and DHMO.
Minimizes financial losses to Guardian by identifying dental care providers that exhibit patterns of practice suggestive of overutilization, bundling, up-coding or other patterns suggestive of potential fraud and or abuse. For both PPO and DHMO.
Participates in the development and maintenance of clinical processing policies which are current, transparent and consistent with current scientific thinking. For both PPO and DHMO.
Works with dental consultants to detect and eliminate fraud, abuse and incorrect claim payments. For both PPO and DHMO.
Minimizes financial losses to Guardian by identifying dental care providers, both PPO and DHMO, that exhibit patterns of practice suggestive of overutilization, bundling, up-coding or other patterns suggestive of potential fraud and or abuse.
Participates in the development and maintenance of clinical processing policies, for both DHMO and PPO, which are current, transparent and consistent with current scientific thinking.
Supports the PPO clinical utilization review team
This position reports to the Chief Dental Officer, who reports to the Vice President, Core Market and Dental Leader Group & Worksite Markets
Adapts to changing business priorities and environments
Strong knowledge of dental benefits industry
Must be proficient in Microsoft Word and Excel
Strong knowledge of CDT
Excellent written and verbal communication skills
Manages multiple projects with multiple deliverables simultaneously
Knowledge of, or willingness to learn, regulatory requirements for dental managed care in the State of Texas
Continuously strives to provide superior products and customer service
Holds self and others accountable for performance
Demonstrates self-awareness and embraces feedback
Dental Degree (DDS or DMD) and Dental License for the state of Texas
Live in Texas
A minimum of five years in clinical dental practice.
MBA MPH or MHA preferred.
Academic experience at a dental school is a plus.
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.
Guardian has been helping people protect their futures and secure their lives for more than 150 years. Every day, we serve approximately 27 million people through a range of insurance and financial products. As one of the largest mutual insurance companies, we know what matters most: putting the needs of our customers first. Because everyone deserves a Guardian. Learn more about Guardian at guardianlife.com.
Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.
© Copyright 2019 The Guardian Life Insurance Company of America, New York, NY
Primary Location: United States-Texas
Job: Dental Insurance
Shift: Day Job
Job Type: Standard
Travel: Yes, 10 % of the Time
Job Posting: Dec 6, 2019, 9:50:13 AM