Department Summary Provide clinical dental expertise and recommendations to support growth of dental line of business and positive member and provider experiences for Blue Cross Blue Cross Blue Shield of Michigan (BCBSM). * Provide input into the development of dental policies, consultation in audit processes and support utilization review activity for cost management and fraud waste and abuse monitoring. * Develop dental clinical policies and procedures and provide interpretation, recommendation, and review within impacted areas of organization and vendor partners. * Provide clinical support and participate in utilization management, quality management, and care management programs in respective areas and identify opportunities for improvement and efficiency. * Review fee schedule changes for impacts and risks and provide clinical guidance for annual CDT changes, including new codes coverage and clinical rules. * Oversee claims appeals escalated from the UM Department or Complaints and Appeals Department. * Work with/oversee provider engagement with internal and external partners to set expectations, establish process improvement, and resolve issues. Additional Responsibilities * Serve as the subject matter expertise to clinical and non-clinical staff, including advising the sales team on how to educate them and respond to market noise. * Develop clinical programs/community events and provide advisement for health promotion and education. * Provide consultation as requested by the Corporate Financial Investigation area in conjunction with the audit staff. * Seek knowledge and provide clinical opinions regarding changes in the healthcare arena, principles of cost containment, emerging dental trends, dental plan coverage, treatment delivery systems, dental technology, and treatment. * Review and provide allowed amounts for accidental dental claims. * Serve as liaison to the Michigan and American Dental Associations and other dental organizations. * Serve as the liaison for the Governmental Program Healthy Kids Dental per the agreement with the State of Michigan. * Promote the value of whole health with dentistry. Focus dental providers on their role and share the importance of oral/overall health connections through outreach, webinars, radio and in-person talks. * Provide clinical and operational insight on new healthcare initiatives and legislation that impact oral health at the state and federal levels. * Serve as the expert and clinical liaison between BCBSM and partners in the oral health space to ensure that the enterprise is represented as a clinical thought leader in the industry. * Assist in establishing corporate and regional initiatives to enhance quality of care, reduce medical costs and achieve positive health outcomes. * Engage proactively with dental practices in and out of the BCBSM network with onsite visits and timely communication so they understand how best to work with Blue Dental. * Provide timely attention, resolution, and communication to escalated inquiries. QUALIFICATIONS * Doctorate of Dental Surgery required. * Ten (10) years experience in clinical practice and dental insurance claims review, audit, utilization review and quality assurance. * Current Michigan Dental license required. * Certification by the American Association of Dental Consultants preferred. Excellent analytical, organizational, problem solving, verbal and written communications skills. * Working knowledge of technical aspects of clinical dentistry. * Extensive knowledge of BCBSM claims review, and policies and procedures. * Ability to evaluate dental research, make difficult decisions and communicate them in a timely manner. * Proficient in current industry standard PC applications and systems. * Other related skills and/or abilities may be required to perform this job.
To view the full job description, click here
