Dental Policy & Quality Manager

GEHA Health

. Own development, documentation, and ongoing maintenance of G.E.H.A.'s dental coverage policies, benefit criteria, code-level guidance, annual CDT updates, and version-controlled policy library .

Posted 10/5/2026full-timeRemote • Kansas • United StatesSeniorLead💰 $93,873 - $118,755 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in dental policy development, CDT coding, and clinical benefit criteria, with a strong focus on regulatory compliance and vendor oversight. Proven ability to lead cross-functional teams and translate complex clinical information into accessible formats for diverse audiences.

Highest-signal resume keywords

Dental Policy DevelopmentCDT Coding ExpertiseRegulatory Compliance KnowledgeVendor Performance OversightClinical Benefit Criteria Evaluation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Dental Clinical TrainingPolicy ManagementClinical Policy GovernanceData AnalysisProject Management

Soft Skills

Strong Written CommunicationAnalytical ApproachCollaborative Working StyleSelf-Directed Accountability

Tools & Technologies

Microsoft Office SuiteContent Management SystemsSharePointBENEFEDSFEDVIP

Certifications & Qualifications

Dental Hygiene LicenseDDS Certification

Industry Keywords

Dental BenefitsManaged CareHealth Plan Regulatory StandardsClinical ReviewAudit Readiness

About the role

Key responsibilities & impact

Own development, documentation, and ongoing maintenance of G.E.H.A.'s dental coverage policies, benefit criteria, code-level guidance, annual CDT updates, and version-controlled policy library
Lead the initial policy audit and realignment effort
Serve as G.E.H.A.'s final dental policy and coding authority for TPA and clinical review vendor alignment, OPM filings, benefit reviews, member escalations, audit findings, and coverage interpretation
Coordinate the annual BENEFEDS CDT reporting process with TPA and Data & Analytics
Chair the clinical policy review process with actuarial, compliance, legal, network, and operations stakeholders
Establish clinical evidence standards and documentation protocols for defensible coverage positions
Provide dental clinical content and review member and provider education materials
Translate complex coverage policy, clinical criteria, and coding requirements into audience-appropriate language
Provide dental policy and coding subject matter expertise to Network Oversight
Serve as clinical representative in escalated provider disputes
Own the clinical review vendor contract and day-to-day relationship, including renewals, invoicing, SLA compliance, performance documentation, and audit-ready records
Monitor vendor performance, determination consistency, clinical accuracy, turnaround compliance, and documentation quality
Direct vendor workflow governance, case routing, quality reviews, policy alignment corrections, updated review criteria, and corrective action plans
Represent G.E.H.A. in OPM audits, site visits, and regulatory inquiries
Advise leadership on regulatory and financial exposure and recommend mitigation
Lead root-cause analysis and remediation for policy-driven claims payment errors
Ensure clinical policy documentation meets evidentiary standards for OPM audits, appeals, and external challenges
Provide technical direction and clinical guidance to external clinical reviewers
Coach and develop internal staff on dental benefit interpretation, CDT coding, and clinical policy reasoning
Serve as escalation point for complex clinical coverage questions, coding disputes, and methodology disagreements
Establish quality standards and review protocols for dental clinical policy and coding work

Requirements

What you’ll need

Bachelor's degree in Dental Hygiene, Health Administration, Health Informatics, or a related field required; advanced degree preferred
Dental clinical training, licensure, or certification (RDH, DDS, or equivalent) required, or demonstrably equivalent clinical depth gained through sustained dental utilization management or clinical policy practice
Deep working knowledge of dental procedures, CDT coding, and clinical benefit criteria required
Additional years of qualifying relevant work experience may be considered in lieu of formal education
Minimum 10 years of progressive experience in dental benefits, dental policy development, dental utilization management, or managed dental care
At least 3 years in a lead or functional authority capacity
Deep subject matter expertise in dental benefit policy, CDT codes, ADA coding guidelines, and dental benefit structures
Experience monitoring, assessing, and implementing annual CDT code updates in a health plan environment
Direct experience developing or maintaining dental coverage policies in a health plan, TPA, or managed care environment
Experience partnering with TPAs or clinical review vendors on policy alignment, adjudication accuracy, and contract performance oversight
Experience establishing clinical policy governance processes, leading clinical policy review forums, or providing technical direction to clinical professionals
Working knowledge of health plan regulatory, compliance, audit, and documentation requirements
Ability to apply regulatory expectations to benefit policy development, coverage criteria, vendor oversight, appeals support, and audit readiness
Ability to apply sound clinical reasoning to evaluate dental necessity, appropriateness, and evidence quality
Strong written communication skills
Analytical and detail-oriented approach
Collaborative and cross-functional working style
Self-directed and accountable, with project management capability
Proficiency in Microsoft Office Suite
Experience with policy management tools, content management systems, or SharePoint preferred
Experience with BENEFEDS, FEDVIP, or OPM-regulated dental benefit programs a significant advantage
Experience developing member or provider education content preferred
Familiarity with dental utilization patterns, post-payment audit findings, or claims data analysis preferred
Ability to provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office
Minimum internet speed of 30 Mbps download and 5 Mbps upload
Latency response time lower than 80 ms
Hotspots, satellite, and wireless internet service are not allowed
Dedicated space without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Competitive pay/salary ranges
Incentive plan
Health/Vision/Dental benefits effective day one
401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
Robust employee well-being program
Paid Time Off
Personal Community Enrichment Time
Company-provided Basic Life and AD&D
Company-provided Short-Term & Long-Term Disability
Tuition Assistance Program
Remote work opportunity
Hybrid and work-from-home options for many roles