Dental Policy & Quality Manager

🕒 il y a 21 jours

🌪️ Kansas – Distant

🌪️ Kansas – Remote

💵 $93 873 - $118 755 / an

⏰ Temps Plein

🟠 Senior

🔴 Expert

👔 Manager

👻 Score fantôme 0%

Ce que ça veut dire : la probabilité que cette offre reste ouverte sans recrutement actif.Comment le lire : 60 % ou plus, on pense que c'est une offre fantôme. Un score plus bas est moins inquiétant.Comment on la calcule : ancienneté, republications, postes ouverts vs taille de l'équipe, rapidité de clôture, et si le salaire est indiqué.À noter : une estimation à partir de données publiques, pas un jugement sur l'entreprise. De vraies offres peuvent avoir un score élevé, alors prenez-le comme un indice, pas comme un fait.

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GEHA Health

Site WebLinkedInTous les Emplois

1001 - 5000 employés

Fondée en 1937

🏥 Santé

🛡️ Assurance

⚕️ Assurance santé

Healthcare • Insurance • Healthcare Insurance

GEHA Health est une grande association de prestations dédiée à servir les employés fédéraux, les retraités et leurs familles. Fondée par des employés des postes en 1937, GEHA propose une gamme complète de plans de santé et dentaires, incluant des options FEHB et PSHB, ainsi que des avantages supplémentaires tels que des abonnements à des salles de sport, des avantages visuels et des récompenses bien-être. Avec un réseau de 1,7 million de prestataires à l'échelle nationale et une couverture étendue des médicaments sur ordonnance, GEHA privilégie la réinvestissement des bénéfices pour améliorer l'expérience des membres et soutenir la santé de la main-d’œuvre fédérale. Leurs plans comprennent des options Medicare Advantage et une offre robuste de télésanté, garantissant à leurs membres le meilleur soin et couverture possible.

Description

• Own development, documentation, and ongoing maintenance of G.E.H.A.'s dental coverage policies, benefit criteria, code-level guidance, annual CDT updates, and version-controlled policy library • Lead the initial policy audit and realignment effort • Serve as G.E.H.A.'s final dental policy and coding authority for TPA and clinical review vendor alignment, OPM filings, benefit reviews, member escalations, audit findings, and coverage interpretation • Coordinate the annual BENEFEDS CDT reporting process with TPA and Data & Analytics • Chair the clinical policy review process with actuarial, compliance, legal, network, and operations stakeholders • Establish clinical evidence standards and documentation protocols for defensible coverage positions • Provide dental clinical content and review member and provider education materials • Translate complex coverage policy, clinical criteria, and coding requirements into audience-appropriate language • Provide dental policy and coding subject matter expertise to Network Oversight • Serve as clinical representative in escalated provider disputes • Own the clinical review vendor contract and day-to-day relationship, including renewals, invoicing, SLA compliance, performance documentation, and audit-ready records • Monitor vendor performance, determination consistency, clinical accuracy, turnaround compliance, and documentation quality • Direct vendor workflow governance, case routing, quality reviews, policy alignment corrections, updated review criteria, and corrective action plans • Represent G.E.H.A. in OPM audits, site visits, and regulatory inquiries • Advise leadership on regulatory and financial exposure and recommend mitigation • Lead root-cause analysis and remediation for policy-driven claims payment errors • Ensure clinical policy documentation meets evidentiary standards for OPM audits, appeals, and external challenges • Provide technical direction and clinical guidance to external clinical reviewers • Coach and develop internal staff on dental benefit interpretation, CDT coding, and clinical policy reasoning • Serve as escalation point for complex clinical coverage questions, coding disputes, and methodology disagreements • Establish quality standards and review protocols for dental clinical policy and coding work

🎯 Exigences

• Bachelor's degree in Dental Hygiene, Health Administration, Health Informatics, or a related field required; advanced degree preferred • Dental clinical training, licensure, or certification (RDH, DDS, or equivalent) required, or demonstrably equivalent clinical depth gained through sustained dental utilization management or clinical policy practice • Deep working knowledge of dental procedures, CDT coding, and clinical benefit criteria required • Additional years of qualifying relevant work experience may be considered in lieu of formal education • Minimum 10 years of progressive experience in dental benefits, dental policy development, dental utilization management, or managed dental care • At least 3 years in a lead or functional authority capacity • Deep subject matter expertise in dental benefit policy, CDT codes, ADA coding guidelines, and dental benefit structures • Experience monitoring, assessing, and implementing annual CDT code updates in a health plan environment • Direct experience developing or maintaining dental coverage policies in a health plan, TPA, or managed care environment • Experience partnering with TPAs or clinical review vendors on policy alignment, adjudication accuracy, and contract performance oversight • Experience establishing clinical policy governance processes, leading clinical policy review forums, or providing technical direction to clinical professionals • Working knowledge of health plan regulatory, compliance, audit, and documentation requirements • Ability to apply regulatory expectations to benefit policy development, coverage criteria, vendor oversight, appeals support, and audit readiness • Ability to apply sound clinical reasoning to evaluate dental necessity, appropriateness, and evidence quality • Strong written communication skills • Analytical and detail-oriented approach • Collaborative and cross-functional working style • Self-directed and accountable, with project management capability • Proficiency in Microsoft Office Suite • Experience with policy management tools, content management systems, or SharePoint preferred • Experience with BENEFEDS, FEDVIP, or OPM-regulated dental benefit programs a significant advantage • Experience developing member or provider education content preferred • Familiarity with dental utilization patterns, post-payment audit findings, or claims data analysis preferred • Ability to provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office • Minimum internet speed of 30 Mbps download and 5 Mbps upload • Latency response time lower than 80 ms • Hotspots, satellite, and wireless internet service are not allowed • Dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Avantages

• Competitive pay/salary ranges • Incentive plan • Health/Vision/Dental benefits effective day one • 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution • Robust employee well-being program • Paid Time Off • Personal Community Enrichment Time • Company-provided Basic Life and AD&D • Company-provided Short-Term & Long-Term Disability • Tuition Assistance Program • Remote work opportunity • Hybrid and work-from-home options for many roles