At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities for all. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It's a mindset, feeling and attitude we wrap around all that we do -- from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description

Directs the clinical and non-clinical activities of the Dental Consulting and Utilization Management department to ensure that department and corporate goals, objectives and requirements are met. The Utilization Management Program is maintained under the management of the Dental Director, and requirements of the Utilization Management Plan are enforced on a day-to-day basis by the Utilization Management Director. The Utilization Management Director oversees and manages all aspects of utilization review by Delta Dental's licensed dentist peer reviewers (dental consultants) including the application of clinical criteria by the reviewers.

Primary Job Responsibilities:

Directs all aspects of claim review and adjudication services provided by licensed professional peer reviewers (dental consultants), including interaction with Professional Services and other Delta Dental of Michigan staff.

Assists in the development, adoption, distribution and updates of clinical criteria, scientific references and professional guidelines to support decision-making by licensed professional peer reviewers.

Directs all aspects of department compliance with applicable federal and state statutes and regulations, code sets, claim processing policies, timely claim adjudication requirements, provider agreements, client contracts and accreditation standards.

Develops, implements, and enforces the requirements of the Utilization Management Plan.

Directs daily, monthly, and annual activities to ensure compliance with applicable NCQA, URAC and other accreditations standards (when, if, and where applicable), including maintenance of continuous survey readiness.

Participates in dental policy development for government programs lines of business.

Manages, trains, and evaluates independent contractors to achieve department and corporate goals and objectives.

Communicates and collaborates with business rules development staff to establish and implement appropriate business rules.

Participates in the development and monitoring of the annual budget for the Dental Consulting and Utilization Management department.

Serves on the Utilization Management Committee, including presenting relevant information, guiding discussion on utilization management issues, and ensuring implementation of committee directives. Also serves on the Quality Assurance and Credentialing/Recredentialing Committees.

Maintains compliance with and performs necessary professional claim review and adjudication services (where appropriate according to professional experience and/or training), including daily monitoring and maintenance of all relevant Roosevelt worklists and filters.

Assigns appropriate professional peer reviewers to those payer worklists and filters commensurate with their degree, training and/or experience.

Evaluates the accuracy of professional peer review determinations from source documentation and develops and implements corrective action plans for any noted exceptions.

Provides ex