Dental Policy & Quality Manager

🔥 12 hours ago

🌪️ Kansas – Remote

🌪️ Kansas – Remote

💵 $93.9k - $118.8k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

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GEHA Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1937

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

GEHA Health is a large benefits association dedicated to serving federal employees, retirees, and their families. Founded by postal workers in 1937, GEHA offers a comprehensive range of health and dental plans, including FEHB and PSHB options, as well as additional benefits such as gym memberships, vision benefits, and wellness rewards. With a network of 1. 7 million providers nationwide and extensive prescription drug coverage, GEHA prioritizes reinvesting profits to enhance member experiences and support federal workforce health. Their plans include Medicare Advantage options and a robust telehealth offering, ensuring their members receive the best possible care and coverage.

📋 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

🎯 Requirements

• 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

🏖️ Benefits

• 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