Texas State Dental Director DHMO

The Texas State Dental Director will be responsible for ensuring that professional DHMO activities in the State of Texas are compliant with applicable state regulations. In this role, you will ensure that referrals, appeals, and grievances meet state specific regulations, timeframes, and definitions for compliance. This role will provide quality oversight and report any quality-of-care issues. In addition, the State Dental Director will be expected to lend support to the entire dental product and to assume responsibility for the functions of utilization management and utilization review, as requested by the Dental Director, Clinical Review. This position will be expected to uphold Guardian’s commitment to ethical business practices. It is expected that in this leadership role, the Dental Director will maintain a strong external focus; that includes the customer, the industry, the provider, the patient, and the regulators. You will Review Specialty Referrals, Claims & Appeals Review & ensure that determination and processing of referrals, claims and appeals meet state regulations, time frames & definitions. DHMO Regulatory Compliance Ensure regulatory and plan compliance with all established policies and procedures, dental and quality management related regulations, guidelines, processes, regulatory audits and if necessary, associated corrective action(s). Expense Management SP Claims: develop, implement, and track SP specific strategies to reduce inappropriate claim costs consistent with plan guidelines. QMP Program & Compliance Demonstrate expertise in QMP processes and protocols. Chair Quality Management Committees (as required by state regulations and in compliance with Company policy and procedures) & ensure timely completion and accuracy of the committee minutes: QAC, QIC, Peer Review, Grievance (i.e., Complaint) and Credentialing Committees. Co-chair the credentialing committee. Dental Director Communication Regular communication with network managers to solve quality, potential quality and/or network issues on a timely basis Communicate and work with Sales to provide clinical expertise for presentations and problem resolutions, as needed. Other Projects & Responsibilities Participate in the development and maintenance of clinical processing policies, for both DHMO and PPO, which are current, transparent, and consistent with current scientific thinking. Complete adjudication of retail claims in a timely manner (queues cleared daily) and communicate any issues to the retail team as they arise. Complete approximately 10hrs/week review of PPO claims. Complete requested peer-to-peer calls educating a Provider on Guardian Clinical Policies and how a clinical determination was completed. Attend all TX DHMO related meetings as well as the monthly team meeting. Provide training and feedback for Reviewing Dentists providing PTO coverage. Maintain or exceed an accuracy rate for clinical determinations of 90%. Maintain or exceed 90% + on the quarterly IRR, Internal Reliability Rating Exercise. You have Dental Degree (DDS or DMD) and Dental License for the state of TEXAS REQUIRED. Reside in the state of Texas, REQUIRED. (Plano, TX is an option should the candidate want to commute into the office) 10+ years' experience in clinical dental practice. Dental benefits industry experience is preferred. Thorough understanding of the dental insurance industry claims management experience, and a substantive knowledge of CDT, policy, and procedures. Proficiency in Microsoft Word and Excel. Demonstrated excellent written and verbal communication skills. Ability to manage multiple projects with multiple deliverables simultaneously. Knowledge of, or willingness to learn, regulatory requirements for dental managed care in the State of Texas. You will Commit to a set schedule, Monday-Friday, 8-5pm, CST. Continuously strive to provide superior products and customer service. Hold self and others accountable for performance. Demonstrate self-awareness and embrace feedback. Adapt to changing business priorities and environments. Location Requirements This is a remote position with travel to Guardian offices, as needed. You must reside in the state of Texas, full-time. Plano, TX is an option should the candidate want to commute into the office Salary Range: $84,320.00 - $138,522.50 The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation. Our Promise At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards. Inspire Well-Being As part of Guardian’s Purpose – to inspire well-being – we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues. Explore our company benefits at www.guardianlife.com/careers/corporate/benefits. Benefits apply to full-time eligible employees. Interns are not eligible for most Company benefits. Equal Employment Opportunity Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law. Accommodations Guardian is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Guardian also provides reasonable accommodations to qualified job applicants (and employees) to accommodate the individual's known limitations related to pregnancy, childbirth, or related medical conditions, unless doing so would create an undue hardship. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]. Current Guardian Colleagues: Please apply through the internal Jobs Hub in Workday. Every day, Guardian helps our 29 million customers realize their dreams through a range of insurance and financial products and services. Our Purpose, to inspire well-being, guides our dedication to the colleagues, consumers, and communities we serve. We know that people count, and we go above and beyond to prepare them for the life they want to live, focusing on their overall well-being — mind, body, and wallet. As one of the largest mutual insurance companies, we put our customers first. Behind every bright future is a GuardianTM. Learn more about Guardian at guardianlife.com. Apply Job!