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Associate Dental Director – Government Programs, Dental Consulting, Utilization Management
Delta Dental of Michigan. Manage assigned clinical staff and support utilization management operations for assigned government programs business .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical expertise in dentistry, including independent clinical judgment and the ability to analyze complex clinical issues. Proficient in managing clinical staff and operations within government programs, ensuring compliance with regulations and standards.
Highest-signal resume keywords
D.D.S. Or D.M.D.Current Dental LicenseTen Years Clinical Dental Practice ExperienceMedicaid And Medicare Advantage ExperienceClinical Practice Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical DeterminationsClaims AdjudicationDental TerminologyRadiograph InterpretationUtilization ManagementQuality AssurancePolicy DevelopmentBusiness Rule ImplementationComplex Problem ResolutionTraining Development
Soft Skills
Strong Written CommunicationStrong Verbal CommunicationInterpersonal SkillsIndependent JudgmentAnalytical Skills
Certifications & Qualifications
State-Specific Dental Licensure
Industry Keywords
Utilization ManagementDental ConsultingGovernment ProgramsQuality-Of-Care ReviewsPeer-To-Peer ReviewsAccreditation StandardsDental Benefits AdministrationOral Health Policy DevelopmentFraud MonitoringClinical System Testing
About the role
Key responsibilities & impact- Manage assigned clinical staff and support utilization management operations for assigned government programs business
- Provide advanced clinical and operational guidance
- Coordinate workload, training, audit consistency, new business readiness, clinical system testing, procedural documentation, and cross-functional issue resolution
- Perform complex clinical determinations for prior authorizations, reconsiderations, appeals, grievances, quality-of-care reviews, peer-to-peer reviews, and state fair hearings
- Perform claims adjudication and processing in compliance with federal and state statutes, regulations, code sets, policies, contracts, and accreditation standards
- Assign and adjust clinical worklists and daily priorities to meet turnaround times and balance workload
- Monitor productivity, quality, turnaround times, calibration, interrater reliability, and adherence to clinical criteria and procedures
- Identify trends and recommend corrective actions
- Coordinate client, state, regulatory, accreditation, and departmental requirements within assigned operations
- Escalate policy, compliance, resource, risk, and systemic concerns
- Provide guidance for claims, prior authorizations, reconsiderations, grievances, appeals, external reviews, state fair hearings, insurance bureau complaints, quality-of-care reviews, and peer-to-peer discussions
- Provide subject matter expertise for clinical system requirements, testing, and process improvements
- Coordinate implementation activities within the dental consulting team
- Maintain training materials, standard operating procedures, and desk-level guidance
- Deliver onboarding, training, calibration, and ongoing development for assigned clinical staff
- Participate in clinical and operational meetings with customers and state partners and coordinate follow-up actions
- Support provider and claim audits and coordinate referrals involving billing anomalies and fraud, waste, and abuse monitoring
- Participate in customer, state-partner, utilization management, credentialing/recredentialing, quality assurance, research, and government programs policy and claims processing meetings
- Perform other related assigned duties
Requirements
What you’ll need- D.D.S. or D.M.D. from an accredited school of dentistry
- Current, unrestricted license to practice dentistry
- State-specific dental licensure as required by the particular state, line of business, or client
- Ten years of clinical dental practice experience
- Previous Medicaid, Medicare Advantage, or dual eligible programs experience preferred
- Experience in clinical practice, dental consulting or state administration, management, dental benefits administration, dental services utilization review and utilization management, business rule development and implementation, or oral health policy development preferred
- Knowledge of dentistry principles and practices
- Knowledge of dental terminology and procedure codes
- Ability to render independent clinical opinions regarding dental conditions, procedures, and treatment
- Ability to review and interpret radiographs and other clinical documentation
- Ability to review and resolve complex clinical and benefit-related issues
- Strong written and verbal communication skills
- Ability to analyze and resolve highly complex problems
- Strong interpersonal skills
- Ability to use independent judgment
- Will accept any suitable combination of education, training, or experience
Benefits
Comp & perks- Equal employment and advancement opportunity without regard to protected characteristics
- Hybrid work arrangement with both in-office and remote work