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Our Florida State Dental Director will be a leadership role in managing our Dental Service Program relationships at the state level, under the direction of the VP of Dental Services. This role includes supporting Dental Program Management efforts to build and maintain network relationships in Florida. Our chosen candidate will effectively interact under Compliance’s leadership and the Quality division within the company’s Florida sponsored Medicaid dental programs, along with other government plans and Commercial Insurance (should Avēsis engage in these programs). Strong emphasis on regular communication with participating network dentists, Provider Relations, Utilization Management and Account Management.

Essential Job Functions:

Clinical Review and Utilization Management

• Assist in coordination of assignment of Dental Consultants for Florida business and assure they complete all necessary claim reviews and authorizations on a timely basis.
• Work with the Associate National Dental Director, Utilization Management to monitor queues and outstanding Pre/Post Authorizations/Appeals.
• Review of Quality Assurance Policies and Procedures, guidelines, and clinical protocols relative to the dental programs, at least annually. Coordinate with UM staff to establish proper referral processes.
• Understand and lead efforts to enforce and review Corrective Action Plans (CAPs) for network dentists imposed by FWA.
• Understand and lead efforts to respond to CAPs presented to Avēsis from clients.
• Be available for review of claims appeals escalated through UM Department or Complaints and Appeals Department. Be available for hearings when necessary.
• Hold peer to peer discussions with participating providers to review quality of care issues, practice deficiencies, appeals or other matters relative to the Dental programs as recommended by Compliance and/or Quality Department.
• Discussion around score cards as it relates to State providers and the interaction with the Quality Department.

Oversight of Committees and Protocols

• Chair of the state Dental Advisory Board.
• Engage and maintain proper representation of the in state Dental Advisory Board based on the respective state’s requirement (provided by Compliance).
• Active participation and regular attendance on the Credentialing Committee, Utilization Review Committee, and State Quality Assurance Committee.
• Assist with review of Policies and Procedures, guidelines, and clinical protocols relative to the Dental programs, at least annually.

Interaction with Avēsis Provider Relations Field Staff

• Conduct office audits with Avēsis Provider Services Field Representatives, as needed.
• Available to coordinate fraud and abuse investigations with the FWA department.
• Available to coordinate with client FWA staff to provide proper reporting on investigations as directed by FWA/Compliance as it relates to CAPs.
• Assistance with decisions regarding referrals and to whom referrals should be made.
• Working with PR and providers in making single case agreements in maintaining continuity of care for members as directed by VP of Dental Services.
• Active participation and regular attendance on quarterly meetings TAC (Technical Advisory Committee)/JOC (Joint Operation Committee) with MCO/PR/AM.

Market and Clinical strategy development

• Facilitate/engagement with State/Local agencies/institutions with New/Upcoming initiatives.
• Working with in-state dental associations in understanding the landscape and evaluating gaps in access of care for members.
• Working with in-state dental schools for potential partnerships on upcoming interventions.
• Working with in-state dental schools in discussion of policies that can be edited as proposed by VP of Dental services for the dental schools to partner with us in acceptance of standards.
• Working with Avēsis Innovation team in developing/discussing/identifying potential vendor/partners in States to assist Avēsis in furthering innovation development.

Management of Dental Consultants

• Holding IRR (Inter Rater Reliability) testing to calibrate with all the Dental Consultants, associated with States to stay