Embrace a brighter future starting with a smile.
We are currently looking for a CONTRACT STAFF DENTIST in WEST VIRGINIA
Must have an active unrestricted license/certification as DDS or DMD with 5+ years of experience as a practicing dentist.
The Staff Dentist will primarily be responsible for the Utilization Management and Utilization Review Programs and ensuring the timely oral health decision-making and adjudication of dental claims and prospective requests for dental services (referrals and pre-authorizations) across all lines of business including Commercial, Medicare Advantage and Medicaid programs to help ensure financial stability and quality of care. A Staff dentist will be involved in state oral health programs of LIBERTY as well as other clinical review activities and duties outlined below.
Job Summary Details:
- Conduct clinical review of claims and pre-authorizations for all lines of business and/or markets as needed to ensure LIBERTY meets their contractual regulatory timeframes.
- Participate in all clinical trainings, calibrations and Interrater reliability testing while also meeting all required quality and calibration benchmarks required by LIBERTY and state/federal regulations.
- Participate and/or complete Quality Management and Improvement activities, DCM and SIU activities (provider site reviews/or consultations, utilization management and utilization review analysis, counseling calls, etc.) and recommend actions to resolve identified provider trends and treatment patterns.
- Conduct Peer-to Peer calls to discuss utilization trends, quality issues and trends in prospective and retrospective claims submissions.
- Conduct secondary reviews such as grievance and appeal review.
- Identify potentially unnecessary services in relation to care delivery settings.
- Identify potential quality issues and trends in prospective and retrospective claims submissions.
- Examine dental charts for focused audits of aberrant utilization and care delivery patterns.
- Occasional on-site chart review for the state provider network.
- Attend meetings of supervisory and administrative staff to discuss department operations, clinical findings and staff training needs.
- Use clinical expertise to make appropriate dental interpretations and decisions, as required.
- Develop and maintain subject matter expertise in LIBERTY dental benefit plans and applicable State Medicaid Programs. As requested, contribute to required regulatory reporting.
- Participate in Quality Improvement and Provider Credentialing Committees and provide input on appropriate resolution of member and/or provider grievances.
- Collect and evaluate data from Grievance, Peer Review, Public Policy, and the Credentialing Sub-Committee on a quarterly basis.
- Participate in enrollee Tele-dentistry visits to provide clinical assessment, evaluations, and recommendations based on dental need.
- May consult periodically with Dental Board-eligible and/ or certified specialist or academic specialist within the community to make informed decision for individual enrollees.
- The position description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee.
Education/Experience:
- Minimum DDS/DMD Degree.
- Active, unrestricted license or certification to practice dental or related health profession in West Virginia in good standing (must pass credentialing - no probation or listed sanctions).
- Minimum 5 years of clinical dentistry experience.
Specific Skills and Knowledge:
- Demonstrated performance in managing oral health care cost and utilization management.
- In-depth knowledge of commercial and managed care delivery systems, reimbursement mechanisms, state regulatory and legislative landscape, and quality improvement initiatives.
- Knowledge of clinical dentistry procedure codes and generally accepted clinical and adjudication guidelines on medical necessity of proposed dental procedures.
- Ability to examine and read dental radiographs and chart records.
- Ability to be successfully credentialed and re-credentialed by LIBERTY Dental Plan.
- Must comply with applicable federal and state statutes and regulations.
- Project management exposure with the ability to create and implement plans successfully.
- Computer literacy with the ability to easily acquire working knowledge of new system applications.
- Ability to apply alternate benefits where applicable, and consistent with plan guidelines and/or generally accepted professional protocols or guidelines.
- Ability to work in a team providing leadership and implementing the consensus or organizational required activities.
- Complete all necessary CE credits associated with maintaining your dental licensure.
- Additional state licensures may be needed to meet regulatory needs of the company.
LOCATION
Our employees are distributed in office locations in multiple markets across the United States. We are unable to hire or allow employees to work outside of the United States.
