Government Dental Officer
Company: Highmark Health
Location: Augusta
Posted on: June 25, 2022
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Job Description:
**Company :** United Concordia Dental **Job Description :**
**JOB SUMMARY** The Government Business Dental Director serves as
the professional dental/clinical authority for the Department of
Defense and Veteran's Affairs Programs, as well as the Centers for
Medicare & Medicaid Services. This position will serve as the
authority and be responsible for overseeing performance of
government business clinical quality assurance, utilization review
and management, and coordinating with the special investigations
unit on fraudulent provider activity. This position will develop
and provide input on provider communications as it relates to
clinical and quality initiatives and quality and appropriateness of
dentalcare delivery. This position will have authority over the
coverage on new dental procedure codes as it relates to government
business. This position will work closely with the Government
Operations team to refine and enhance claim adjudication processes
and resolution of appeals and grievances as necessary. This
position will work with the Provider Network Development and
Maintenance team to ensure access to care for Government business
and meet with providers as necessary to ensure adequate access to
dental care for members. This position will work closely with the
commercial business Chief Dental Officer and quality assurance team
to develop dental policy and quality assurance guidelines in order
to ensure consistent practices when appropriate. The position will
work closely with the SVP of Government Business and the Government
Business team to identify new business opportunities and assist in
proposal preparation. **GENERAL OVERVIEW** +
Oversight/coordination/completion of utilization review activity,
grievances, appeal processes, and dental advisor review processes.
+ Development and oversight of Quality Assurance for federal
programs in coordination with the Government. + Development of
dental review policy and criteria, and exclusions and limitations
as directed by the Government. + Certain clinical aspects of
product development, contractual provisions, and professional
communications + Provide clinical expertise, as necessary, in
dental policy interpretation/application, and in pre-payment and
post payment reviews of submitted claims + Provide guidance to
dental advisors, as it relates to applying clinical criteria
directed by the Government for claims and pre-determinations. +
Serve as the clinical liaison with the Defense Health Agency,
Dental Treatment Facility Commanders, and Dental Service Points of
Contact + Serve as a liaison to the professional dental community
and representing the company with various government agencies +
Develop specific training for providers on the information in the
Dental Reference Guide + Management of the TDP/ADDP network Pay for
Performance programs. Review efficacy and make appropriate changes
on a yearly basis. + Work with the UCCI Chief Dental Officer to
provide guidance on clinical initiatives across the company's
commercial and government business + Develop training program
regarding DoD dental readiness classification application for DoD
service members. Identify specific providers that may need remedial
guidance and reach out to them for assistance. + Assist the Network
Development Team with network access matters + Periodic nationwide
travel is also required. **ESSENTIAL RESPONSIBILITIES** + Lead and
oversee utilization review and quality assurance endeavors. The
Government Business Dental Director ensures the provision of
proactive patient care that optimizes the dental health of the
patient population, while minimizing costs and educating those
involved. This requires coordination of activities with civilian
dentists, UCCI personnel, senior management, dental advisors,
professional societies and regulatory agencies. The incumbent must
make recommendations in regard to dental policy concerning
eligibility and necessity to the Government. Additionally, the
incumbent must provide guidance regarding referrals to specialists,
treatment plans, alternate delivery mechanisms, ancillary services
and dental health management emerging technologies. + The incumbent
may be called upon to represent UCCI during legal proceedings
subsequent to fraud investigations. The Government Business Dental
Director also participates in UCCI quality assurance, utilization
review, and related task forces or committees, such as those
related to cost of care, pilot dental projects, and procedures
subject to abuse, etc. + Oversee professional input to dental
policy administration and claims adjudication. This position is the
dental authority for the government programs and as such is
responsible for all clinical aspects of dental policy, pre-payment
dental advisor claim adjudication, grievances and appeal processes,
clinical professional communications, and related documentation and
training. This includes coordination of retrospective review and
appeal processes, as well as conferring with peer consultants
retained to provide dental counsel, to ensure that subsequent
decisions and recommendations are based on an accurate assessment
of the medical, clinical, financial, and behavioral factors at
hand. Such information in turn provides a foundation for decisions
in regard to utilization issues and opportunities related to
fraud/misreporting, claims processing protocols, patient education,
provider feedback, dental policy, grievance resolution, quality
improvement, etc. This may include definition of appropriate action
to be taken in dealing with specific claim circumstances, personal
review of highly complex or unusual claims or priority inquiries,
and provision of professional advice related to new findings and
developments in dental practice theory, technology, or materials. +
Lead critical professional affairs activities on government
programs. Most notably, these activities involve responding to
inquiries/areas of noncompliance identified; providing RFP input
for large or otherwise critical business prospects; providing
clinical advice relative to changes to plan benefit designs; and
leading or participating in other projects as business needs
dictate. + Communicate professional concepts to a variety of
audiences. The Government Business Dental Director serves as a
liaison to the professional dental community, and represents UCCI
in industry, governmental, and public relations capacities. This
includes, for example, making presentations to professional
societies, contributing articles to internal and external journals
and publications and communicating professional concepts to lay,
professional, and regulatory audiences. Ensure that qualified
clinicians are accountable to the organization for decisions
affecting members. **ADDITIONAL RESPONSIBILITIES** + Perform other
duties commensurate with the position + Represent UCCI on
government work groups or committees as appropriate + Ensure
consistency of national policy and standard language relative to
other regions of the United States. + Attend conferences, as
available, to maintain up-to-date knowledge of emerging technology,
findings, trends, etc. **EXPERIENCE** **Required** + 10 years of
experience in military dentistry + 10 years in a leadership
position + Bachelors degree **Preferred** + Masters in Business
Administration **LICENSES OR CERTIFICATIONS** + DDS or DMD
**SKILLS** + Exemplary communications, presentation, writing, and
human + relations skills, as well as a familiarity with information
systems and PC based spreadsheet and data processing applications.
+ A strong customer service orientation **Language (Other than
English):** None **Travel Requirement:** 0% - 25% **PHYSICAL,
MENTAL DEMANDS and WORKING CONDITIONS** **Position Type**
Office-based Teaches / trains others regularly Occasionally Travel
regularly from the office to various work sites or from
site-to-site Rarely Works primarily out-of-the office selling
products/services (sales employees) Never Physical work site
required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25
pounds Occasionally Lifting: 25 to 50 pounds Rarely
**_Disclaimer:_** _The job description has been designed to
indicate the general nature and essential duties and
responsibilities of work performed by employees within this job
title. It may not contain a comprehensive inventory of all duties,
responsibilities, and qualifications required of employees to do
this job._ **_Compliance Requirement_** _: This job adheres to the
ethical and legal standards and behavioral expectations as set
forth in the code of business conduct and company policies._ _As a
component of job responsibilities, employees may have access to
covered information, cardholder data, or other confidential
customer information that must be protected at all times. In
connection with this, all employees must comply with both the
Health Insurance Portability Accountability Act of 1996 (HIPAA) as
described in the Notice of Privacy Practices and Privacy Policies
and Procedures as well as all data security guidelines established
within the Company's Handbook of Privacy Policies and Practices and
Information Security Policy._ _Furthermore, it is every employee's
responsibility to comply with the company's Code of Business
Conduct. This includes but is not limited to adherence to
applicable federal and state laws, rules, and regulations as well
as company policies and training requirements._ Highmark Health and
its affiliates prohibit discrimination against qualified
individuals based on their status as protected veterans or
individuals with disabilities, and prohibit discrimination against
all individuals based on their race, color, religion, sex, national
origin, sexual orientation/gender identity or any other category
protected by applicable federal, state or local law. Highmark
Health and its affiliates take affirmative action to employ and
advance in employment individuals without regard to race, color,
religion, sex, national origin, sexual orientation/gender identity,
protected veteran status or disability. Highmark Health and its
affiliates prohibit discrimination against qualified individuals
based on their status as protected veterans or individuals with
disabilities, and prohibit discrimination against all individuals
based on their race, color, age, religion, sex, national origin,
sexual orientation/gender identity or any other category protected
by applicable federal, state or local law. Highmark Health and its
affiliates take affirmative action to employ and advance in
employment individuals without regard to race, color, age,
religion, sex, national origin, sexual orientation/gender identity,
protected veteran status or disability. EEO is The Law Equal
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Keywords: Highmark Health, New England , Government Dental Officer, Government & Protective Services , Augusta, Northeast
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