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<div><strong>Job Description</strong><br/><br/><strong>JOB DESCRIPTION</strong><br/><br/>Provides support and subject matter expertise for member clinical dental review activities. Responsible for determining appropriateness and medical necessity of member dental care services - targeting opportunities for quality improvement and satisfaction for members and providers. Participates with senior leadership to establish strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care.<br/><br/><strong>Essential Job Duties</strong><br/>• Oversees all aspects of utilization review and quality management activities related to dental care services for members, including appropriateness and medical necessity of dental care services provided.<br/> • Provides oversight for dental quality programs including Healthcare Effectiveness Data and Information Set (HEDIS) and Pay For Performance (P4P).<br/> • Develops and implements clinical utilization processes and algorithms utilized in the authorization process including: statistical methodology for use in utilization management, provider profiling analytics, dental policies and procedures and quality improvement activities.<br/> • Partners with provider contracts to secure and maintain a network of dental providers.<br/> • Meets or exceeds established review productivity standards.<br/> • Educates and interacts with network and group providers regarding utilization practices, guideline usage, and effective member management; provides clinical representation for business presentations in partnership with provider relations.<br/> • Provides guidance to staff regarding appeals, grievances and member/provider complaints.<br/> • Provides analytics and interpretation of dental benefit plan structures.<br/> • Maintains accountability for consumer/member related decisions for self and network of dental consultants.<br/> • Ensures that the dental care provided meets the standards for acceptable dental care and that dental protocols and rules of conduct for plan personnel are followed.<br/> • Participates in professional and community activities to provide input/demonstrate dental knowledge related to regulatory, professional and community standards, and issues. <br/><br/><strong>Required Qualifications</strong><br/>• At least 7 years of dental practice experience, including 3 years of experience working in a managed care, insurance, or benefits administration setting, or equivalent combination of relevant education and experience.<br/> • Doctor of Medicine in Dentistry (DMD) or Doctor of Dental Surgery (DDS). License must be active and unrestricted in state of practice.<br/> • Health care management/leadership experience preferred.<br/> • Current clinical knowledge.<br/> • Ability to gather information and coordinate workflows.<br/> • Ability to work independently and within a team environment.<br/> • Effective time-management and organizational skills.<br/> • Critical thinking and listening skills.<br/> • Decision-making and problem-solving skills.<br/> • Excellent verbal and written communication skills.<br/> • Microsoft Office suite/applicable software program(s) proficiency.<br/><br/><strong>Preferred Qualifications</strong><br/>• Peer review, medical policy/procedure development and provider contracting experience. <br/> • Knowledge of National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), Medicare, Group/Independent Physician Association (IPA), capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines.<br/><ul> <li>Active dental licensure in Southwest region (AZ, CA, NV, NM, TX).</li> <li>Active membership in a recognized professional organization, such as the American Dental Association (ADA) or National Dental Association (NDA).</li></ul><br/>To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.<br/><br/> Molina Healthcare offers a competitive benefits and compensation package.</div>
