Job Description

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.

Essential Job Duties

• 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.

• Provides oversight for dental quality programs including Healthcare Effectiveness Data and Information Set (HEDIS) and Pay For Performance (P4P).

• 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.

• Partners with provider contracts to secure and maintain a network of dental providers.

• Meets or exceeds established review productivity standards.

• 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.

• Provides guidance to staff regarding appeals, grievances and member/provider complaints.

• Provides analytics and interpretation of dental benefit plan structures.

• Maintains accountability for consumer/member related decisions for self and network of dental consultants.

• 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.

• Participates in professional and community activities to provide input/demonstrate dental knowledge related to regulatory, professional and community standards, and issues.

Required Qualifications

• 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.

• Doctor of Medicine in Dentistry (DMD) or Doctor of Dental Surgery (DDS). License must be active and unrestricted in state of practice.

• Health care management/leadership experience preferred.

• Current clinical knowledge.

• Ability to gather information and coordinate workflows.

• Ability to work independently and within a team environment.

• Effective time-management and organizational skills.

• Critical thinking and listening skills.

• Decision-making and problem-solving skills.

• Excellent verbal and written communication skills.

• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Peer review, medical policy/procedure development and provider contracting experience.

• 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.

• Active dental licensure in Southwest region (AZ, CA, NV, NM, TX).
• Active membership in a recognized professional organization, such as the American Dental Association (ADA) or National Dental Association (NDA).
  
  

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V