Texas State Dental Director DHMO
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Job Location:
Monthly Salary:
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
The Dental Director will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. You will ensure that claims referrals appeals and grievances meet state specific regulations timeframes and definitions for compliance. You will provide quality oversight and report any quality-of-care addition the State Dental Director will be expected to lend support to the entire dental product and to assume responsibility for the functions of utilization management and utilization review as requested by the Dental Director Clinical Review. This position will be expected to uphold Guardians commitment to ethical business practices.
Responsibilities
Review & ensure that determination and processing of claims referrals and appeals meet state regulations time frames & definitions.
Complete adjudication of retail claims timely (queues cleared daily) and communicate issues to the retail team as they arise
Complete peer-to-peer calls educating Providers on Guardian Clinical Policies and clinical determination
Complete approximately 10-15hrs/week review of group PPO claims
Participate in the development and maintenance of clinical processing policies for both DHMO and PPO.
Ensure regulatory and plan compliance with all established policies and procedures dental and quality management related regulations guidelines processes regulatory audits and associated corrective action(s).
Assist in project work by updating any existing guidelines/manuals as needed (e.g. Specialty Referral Guidelines) with guidance from the Quality and Utilization Management Manager.
Demonstrate expertise in QMP processes and protocols.
Chair Quality Management Committees (as required by state regulations and in compliance with Company policy and procedures) & ensure timely completion and accuracy of the committee minutes: QAC QIC Peer Review Grievance (i.e. Complaint) and Credentialing Committees.
Co-chair the credentialing committee.
Additional responsibilities:
Communicate and work with Sales to provide clinical expertise for presentations and problem resolutions
Attend all TX DHMO related meetings as well as the monthly team meeting.
Adhere to and meet departmental metrics and performance expectations
You have
Dental Degree (DDS or DMD) and Dental License for the state of Texas
Reside in the state of Texas
A minimum of ten years in clinical dental practice
MBA MPH or MHA preferred.
Dental benefits industry experience is preferred
A thorough understanding of the dental insurance industry claims management experience and a substantive knowledge of CDT policy and procedures
Proficiency in Microsoft Word and Excel
Excellent written and verbal communication skills
Ability to manage multiple projects with multiple deliverables simultaneously
Knowledge of or willingness to learn regulatory requirements for dental managed care in the State of California
You will
Continuously strive to provide superior products and customer service
Hold self and others accountable for performance
Demonstrate self-awareness and embrace feedback
Adapt to changing business priorities and environments
Reporting Relationships
This position reports to the Dental Director Clinical Review.
Location Requirements
The primary location for this position is remote with work from home flexibility. Travel to Guardian offices as needed.
Salary Range:
$96960.00 - $159300.00The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education experience knowledge and abilities of the successful addition to salary this role may also be eligible for annual sales or other incentive compensation.
Our Promise
At Guardian youll have the support and flexibility to achieve your professional and personal goals. Through skill-building leadership development and philanthropic opportunities we provide opportunities to build communities and grow your career surrounded by diverse colleagues with high ethical standards.
Inspire Well-Being
As part of Guardians Purpose to inspire well-being we are committed to offering contemporary supportive flexible and inclusive benefits and resources to our colleagues. Explore our company benefits at apply to full-time eligible employees. Interns are not eligible for most Company benefits.
Equal Employment Opportunity
Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age race color creed religion sex affectional or sexual orientation national origin ancestry marital status disability military or veteran status or any other classification protected by applicable law.
Accommodations
Guardian is committed to providing access equal opportunity and reasonable accommodation for individuals with disabilities in employment its services programs and activities.Guardian also provides reasonable accommodations to qualified job applicants (and employees) to accommodate the individuals known limitations related to pregnancy childbirth or related medical conditions unless doing so would create an undue hardship. If reasonable accommodation is needed to participate in the job application or interview process to perform essential job functions and/or to receive other benefits and privileges of employment please contact .
Current Guardian Colleagues: Please apply through the internal Jobs Hub in Workday.
Required Experience:
Director
Key Skills
- Office Manager Experience
- Accounts Receivable
- Dentrix
- Computer Operation
- ICD-10
- Dental Receptionist
- Chairside Assisting
- Dental Office Experience
- Medical Billing
- Front Desk
- CPT Coding
- Eaglesoft
