Job Description

The Manager of Clinical Quality and G&A Review is responsible for overseeing the day-to-day operations of the clinical appeal review process, and performing activities that evaluate and improve the quality and safety of care and services. This individual will also assist in the design and implementation of quality improvement initiatives in support of the strategic objectives of the organization.

• Responsible for the operational execution of clinical quality management (QM) activities and appeal day-to-day operations; guides Clinical QM/G&A units to meet and exceed department quality, compliance, timeliness and production goals.
• Provides overall clinical leadership and governance for the Grievance & Appeals (G&A) Department, ensuring all clinical reviews are conducted in accordance with regulatory standards and organizational policies ensuring consistent application of plan policies and contractual requirements.
• Oversee monitoring and reporting as required by regulation or contract; Identifies provider trends discovered through PQI, PQR and G&A case review.
• Analyzes clinical trends and outcomes to identify emerging risks, assesses potential quality concerns, and uncover opportunities for process improvement, while driving strategic initiatives across internal teams and cross-functional partners.
• Identifies potential quality risks or opportunities for process improvement and implements appropriate courses of action.
• Serves as clinical subject matter expert, providing guidance to internal stakeholders and collaborating cross-functionally to deliver processes procedures, and systemic training opportunities and efficiencies to support QM and appeal team members.
• Develops P&Ps, workflows and required documents to meet federal and state regulatory requirements.
• Oversees health promotion and quality initiatives.
• Acts as educator and resource to departments in matters of health care quality.
• This list is not all-inclusive and you are expected to perform other duties as requested or assigned.

• 8+ years w/Bachelor’s degree; 1+ years supervisory/management
• 2-3 years' experience Quality Management Review, Denial Management, Case Management, or related experience, including leadership in a clinical operational area
• Minimum 5 years' experience in health insurance
• Excellent organizational and time management skills, with the ability to meet strict internal and regulatory deadlines with highly confidential information.
• Ability to establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.
• Excellent written, verbal, and electronic communication skills.
• Strong critical thinking, problem-solving, and decision‐making/resolution skills.
• Excellent team building, training, and leadership skills.
• Intermediate knowledge of Microsoft Office programs including Word, Excel, and Outlook.

Licenses

• Unrestricted California Dental License Required
• Certified Project Management Professional (PMP)-PMI. Preferred
• Six Sigma Green Belt Certification. Preferred

Base Pay Information

The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.
Pay Grade 22. $93,445.00 - $202,465.00.

Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes: