Job Description:

Summary: 

This position is a leadership role in managing the Medicaid dental network and directing government dental relationships at the Pennsylvania state level, under the direction of the Vice President, National Dental Director.  This role includes supporting Dental Program Management efforts to build and maintain network relationships in Pennsylvania, and effectively monitor and control fraud, waste and abuse (FWA) activity within the company’s state sponsored Medicaid dental programs and other government plans.  Strong emphasis on regular communication with participating network dentists.

 

Essential Job Functions and Responsibilities:

 
Claim Review and Utilization

• Assist in coordination of assignment of Dental Consultants for Pennsylvania business with the Vice President, National Dental Director to complete all necessary claim reviews and authorizations on a timely basis.


• Work with the Clinical Dental Director, Utilization Management to monitor queues and outstanding claims.


• Review of Quality Assurance Policies and Procedures, guidelines and clinical protocols relative to the dental programs, at least annually.  Coordinate with UM staff to establish proper referral processes.


• Understand and lead efforts to enforce and review Corrective Action Plans (CAPs) for network dentists.


• Understand and lead efforts to respond to CAPs presented to Avesis from clients.

 
Oversight of Committees and Protocols

• Chair of the state Dental Advisory Board.


• Active participation and regular attendance on the Credentialing Committee, Utilization Review Committee, State Quality Assurance Committee, and Fraud, Waste and Abuse Committee.


• Assist with review of Policies and Procedures, guidelines and clinical protocols relative to the Dental programs, at least annually.

 
Coordination of Appeals and Client Issues

• Be available for review of claims appeals escalated through UM Department or Complaints and Appeals Department. Be available for hearings when necessary.


• Hold peer to peer discussions with participating providers to review quality of care issues, practice deficiencies, appeals or other matters relative to the Dental programs.

 
Interaction with Avesis Provider Relations Field Staff

• Conduct office audits with Avesis Provider Services Field Representatives, as needed.


• Available to coordinate fraud and abuse investigations with the FWA dental unit.


• Available to coordinate with client FWA staff to provide proper reporting on investigations.


• Assistance with decisions regarding referrals and to whom referrals should be made.

 
Other

• Clinical oversight for all aspects of Pennsylvania dental programs including plan design, review of new methodologies, appropriateness of care, etc.


• Discussion, if necessary, with CMO medical directors.


• Other duties as assigned.

Qualification Requirements:

 
Education:

• College degree.


• DDS or DMD; holder of Pennsylvania license.

 
Experience:

• A minimum of seven (7) years’ experience as a practicing dentist or dental specialist.

 
Skills:

• Clear communication skills.


• Effective project management skills.


• Strong presentation skills.


• Word processing; Ability to learn claim processing systems; Familiarity with MicroSoft Excel spreadsheets.

 
Knowledge:

• Experience in delivery of dental care; knowledge of government and commercial plan designs and administration a plus.

 
Other:

• Completion of credentialing process following NCQA guidelines.


• Travel: Occasional.

 

About Avesis:

Avesis has been providing essential ancillary benefit solutions since 1978. Since its inception Avesis has developed, administered and refined its offerings to provide clients with best-in-class product choices and services. Today, our programs cover millions of members throughout the country. We strive for excellence in all that we do and our benchmark performance in terms of member satisfaction and client retention underscores this singular focus.

The continued upward spiral in health care costs has challenged sponsors, providers and payers of health benefits to deliver high quality care in the most cost-effective manner possible. The Avesis benefits menu has been created to meet that challenge by making available quality essential ancillary benefit services at the lowest possible price while never sacrificing the highest quality of service. Providing outstanding customer service is a top priority, and our core values of accountability, empowerment, excellence, and integrity help us achieve high member and client satisfaction.

As of January 2016 Avesis is a wholly-owned, independent subsidiary of The Guardian Life Insurance Company, a distinction that brings even more capabilities to Avesis. The Guardian is a Fortune 250 mutual insurance company that has put its policyholders and clients above all else for more than 150 years, and it has earned them not only a great reputation but awards and accolades from such authorities as J.D. Power. Adhering to high standards, doing the right thing, and making people count are the founding principles that has kept Guardian financially sound and made them one of the largest insurance companies in the country.

In January 2017, Premier Access joined the Avesis family. Premier Access has focused on direct state contracts for Medicaid and Chip, specifically in California and Utah. They were one of the original participants in the Chip and Medicaid programs.

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