Dental Director, 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:

JOB SUMMARY:

The Dental Director is a liaison between DentaQuest, the dental community and key oral health stakeholder in the assigned market and will represent DentaQuest in a variety of professional settings. The Dental Director is responsible for partnering with CPE team members and applicable internal departments to ensure State and Federal guidelines, clinically sound and contractually required principles are applied in managing various client contract terms and corresponding initiatives. Under the Dental Director’s guidance, DentaQuest will ensure effective PIPs, Quality programs, member outreach/wellness initiatives, care coordination processes, claims cost management plans and innovation are developed, implemented and managed to meet market targets.  When deemed necessary and appropriate within a market, the Dental Director will focus on the proper provision of medically necessary covered services for enrollees and remain closely involved in the monitoring of program integrity, quality, utilization management, and utilization review.

JOB DUTIES AND RESPONSIBILITIES:           

• Provide input on Performance Improvement Projects (PIPs).
• Chair or hold a lead role in market peer review committees.
• Participate in internal committees, such as, but not limited to: Quality Monitoring Program (QMP) Committee, Credentialing Committee and Clinical Committee.
• Serve on external committees specific to each market, such as oral health coalition and oral health alliance.
• Attend and present when needed at local Dental Advisory Committee meetings.
• Attend dental association and/or society meetings, dental conferences, individual provider meetings and provider training sessions.
• Interpret contract benefits, design benefit plans and provide recommendations regarding modifications to clinical principles in accordance with State and Federal policy.
• Work with MCO Medical Directors, UM and QM staff to integrate dental and medical programs.
• Assist Provider Engagement team with peer-to-peer requests.
• Accept feedback and questions from participating dentists and share appropriate information and actions taken with DentaQuest team members.
• Provide guidance on state and federal policies and regulations.
• Upon request from provider engagement team, review authorization requests and associated documentation (i.e. patient records, x-rays, notes) to help determine if an initial clinical decision rendered by UM should be upheld or overturned.
• Assist with and/or review member and provider complaints and appeals; and participate in fair hearings where applicable based on market needs and responsibilities.
• Assist in identifying, reviewing and monitoring any necessary provider corrective action or removal from the network.
• Audit claims and patient charts where applicable based on market needs and responsibilities.
• Perform site visits to address quality of care concerns or provider outreach and education, as necessary.
• Partner with CPE and Data Analytics teams to determine and implement effective cost containment initiatives.
• Assist Case management department.
• Partner with CPE and Quality teams to determine, implement and oversee member and provider outreach initiatives and wellness programs to meet HEDIS, CMS416 and other contractually required quality targets.
• Maintain relationships within local Dental Association, Hygiene Association, oral health coalition, dental schools, Federally Qualified Health Centers, Department of Health and other market and/or client contract applicable key dental stakeholders.
• Assist in organizing community events and partner with culture ambassadors.
• Work with Impact Group on initiatives such as Tele dentistry, ED Diversion, Value Based Purchasing, etc.

REQUIRED QUALIFICATIONS:

• Graduate of an accredited