Payment & Outcomes Rules Manager

The Manager of Payment Rules & Outcomes is a key strategic leader in managing Delta Dental's health care industry rule practices, rule architecture, business capabilities, and administration of clinical and non-clinical policies to ensure quality outcomes and accurate payment. This role leads a team of analysts that support identification of new rules to enable policy and ensure quality outcomes and accurate payments, while also monitoring the efficacy of existing rules. This Manager is a trusted thought partner to support the various Quality and Enterprise efforts driving quality outcomes and delivering quality of care.

• Oversees business and clinical policy administrative rules and business “ownership” for the tool(s) enabling claim or clinical outcome rules; including oversight of any external third-party partners that are administering claim outcome and/or payment rules on Delta Dental’s behalf to ensure consistent and accurate outcomes and performance.
• Leads a team of Outcome Rules Analysts that work cross-functionally to ensure Delta Dental has the right monitoring and controls in place to continuously and proactively evaluate rules in production, ensuring accuracy and effectiveness.
• Leads cross-functional discussions with various Data, Analytics, Reporting, Insights, Technology and Business stakeholders to discuss new opportunities within the claims and clinical ecosystem, and to formulate recommendations and comprehensive remediation plans inclusive of holistic business cases for any new, enhanced or eliminated rules.
• Ensures outcome rules are appropriately accessible and transparent both internally and externally, and supports enterprise-wide educational opportunities.
• Leads health care industry research to ensure best practice rule management methodologies are documented, implemented, and communicated to stakeholders regularly.
• Develops and maintains a comprehensive approach to analysis and reporting of outcome rule performance, trends and opportunities that are accessible to stakeholders.
• Leads cross-functional discussions to influence Policy and Payment Quality Management strategy, prioritization and multi-year roadmaps.
• Develops and maintains strong partnerships with functional leaders (including Business Directors, Senior Product Managers, Technology Managers, and other Product Managers), across the enterprise to drive focus on business objectives.
• Manages and develops multi-disciplinary teams to achieve strategic objectives, encompassing determining staffing needs, setting goals, monitoring performance, interviewing, selecting, coaching, and evaluating the performance of all direct reports, overseeing, and maintaining department budgets.

• 8+ years w/Bachelor’s degree; 1+ years supervisory/management. 
• Additional experience may be accepted in lieu of education or degree.
• Experience in claims and/or clinical outcome determination preferred. 
• Experience in aggregating internal and external complex information to address business problems and working cross-functionality to build the story and deliver the message to Sr. Leaders in support of business decisions.
• Strong people-leadership skillset, including talent development and the ability to realize strategies through a team.
• High detail orientation with strong analytical, critical thinking and problem-solving skills.
• Excellent organizational/time management and project management skills.
• Extensive knowledge of health care industry.
• Excellent interpersonal, verbal, and written communication skills, including proven ability to collaborate and influence across all functions and levels of the organization.
• Proven ability to resolve conflict and facilitate decision-making.
• Strong presentation skills. Should be comfortable with presenting to all levels of management.
• A problem solver and planner, has strong quality control, adaptability, and customer service skills.
• Ability to break down complex problems into pieces that can be solved with data, analysis, assumptions, and judgment.
• Ability to synthesize large amounts of complex information to determine correlations in the data and summarize in a way that is digestive to stakeholders.
• Ability to represent the business and work cross-functionally to ensure the enterprise is deploying the right rules and optimal solution patterns for accurate policy and payment administration.
• Advanced technical knowledge is preferred.

Base Pay Information

The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. O