Director, Utilization Management - DentaQuest

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:

Location: We support US flexible working arrangements in the contiguous 48 states.

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America. 

The opportunity:
The Director, Utilization Management participates in the design, strategic planning, development, implementation, and administration of all aspects of the utilization management programs.  The scope of utilization management is inclusive of technologies that improve efficiency, quality, and accuracy. The position maintains delivery of a high value (both clinical and financial) utilization management program and for assuring members receive high quality and appropriate clinical care in a timely and cost-effective manner. The Director will also be responsible for developing strong cost and quality oversight procedures with and vendor or sub-delegate partner. 

How you will contribute:

• Ensures that the right systems, processes, and measurements are in place to demonstrate the value and clinical effectiveness of utilization management programs to customers.
• Enhances operational efficiency to optimize and maximize staff and external partner productivity and value.
• Contribute to business unit objectives through the recommendation, development, and implementation of utilization management models.
• Work with other internal departments as necessary to implement strategies and programs to proactively manage dental utilization costs within each market to assure profitability and budgetary goals are met.
• Develops and implements process and program redesigns.
• Handle detailed utilization evaluation and benchmarking
• Manage department budget.
• Oversee projects that improve efficiency and ensure resultant budgetary and performance goals are measured and achieved.
• Maintain relationships with client contacts and attend in person client or sales meetings as needed.
• Represents DentaQuest to a variety of external stakeholders including provider organizations, customers, advocacy groups and government entities as needed.
• Manages relationships and operations with external partners/vendors that provide services as part of the UM program.
• Oversee and direct utilization management department personnel and metrics to ensure compliance with business unit objectives.
• Meets applicable regulatory and compliance standards and accreditation requirements by maintaining a continuous quality improvement program to aid external and internal audits.
• Develop team by managing the overall activities of the department including employee coaching, development, and review.
• Develop and manage staffing models and operational processes to ensure analysis, data, reports, initiatives, and projects are completed accurately and efficiently to meet organizational and client needs.
• Responsible for assuring the documentation, monitoring, and development of training material and training of departmental staff in utilization management guidelines and processes.
• Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Provide recommendations on department policies, objectives, and initiatives. Evaluate and suggest changes as necessary to optimize processes and efficiencies. Works in partnership with technical team and or vendors to improve system efficiency and remains current on industry trends and technologies.
• Establishes department goals and performance metric