Resp & Qualifications
PRINCIPAL ACCOUNTABILITIES: Under the supervision of the Chief Medical Officer, the incumbent’s accountabilities include, but are not limited to:
1. Completes and oversees dental plan professional claim reviews and medical plan dental claim reviews, pre-certification determinations, adverse decision appeals and quality improvement actions. Supervises dental consultants and represents CareFirst in legal challenges involving dental claims. Update and/or revise dental clinical or dental-related medical policies. Collaborates with Special Investigation Unit and law enforcement authorities for fraud and other investigations. Overall management of the dental UR/UM program – Duties include but are not limited to: Clinical training, updating consultant manuals; quarterly audits of claim reviewers, SOP revisions and establishing policy.
2. Supervises dental utilization review and utilization management programs. Develops strategies and programs to assure appropriate and cost effective dental care for CareFirst Members. Updates dental and medical policies to reflect the current state of oral health care delivery.
3. Maintain engagement with dental community. Establishes network access standards and determines dental provider allowances to assure competitive rates and maintain adequate networks. Supervises the recruitment of participating dentists for traditional and preferred provider networks. Negotiates provider specific pricing arrangements for dentists in underserved areas. Coordinates dental allowance changes with corporate pricing, actuary and finance departments to assure marketable dental premiums and a profitable dental business. Reviews credentialing documents and dental board orders to assure Corporate credentialing standards are being met.
4. Oversees dental plan claim administration by assuring correct implementation of contract provisions, benefit levels, applicable state and federal regulations, and community standards of care. Incumbent has the authority to override established benefit levels when necessary. Serve on the Dental Leadership Group and governance boards as appointed. Chair the Dental Advisory and Oral Surgery Advisory Committees. Co-chair the Credentialing Committee.
SUPERVISORY RESPONSIBILITY: This position manages a staff of 2.5 FTE’s.
Required: Bachelor’s degree in a related field and at least 8-10 years of progressively responsible managerial experience in dental health care or medical management. This position requires a thorough knowledge of oral health care and experience in the practice of dentistry. Knowledge of the community standards of oral health care delivery and dental care benefit administration is also required. The incumbent must be licensed to practice dentistry in Maryland and/or DC and/or Virginia and/or Delaware without restriction and be an active participant in organized dentistry. Current license to practice in Maryland.
Abilities/Skills: Excellent organizational skills and communication skills, both verbal and written. Strong interpersonal skills needed. Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Preferred: Board Certification. Completion of a general practice hospital-based residency or completion of a 2 year AEGD program, FAGD or MAGD certificate.
AEGD Advanced Education in General Dentistry
FAGD Fellow, Academy of General Dentistry
MAGD Master, Academy of General Dentistry
Department: Dental Director
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 6/30/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship