State Dental Director

Texas State Dental Director DHMO Fully Remote Work From Home - TX Full time 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. You will ensure that claims, referrals, appeals, and grievances meet state specific regulations, timeframes, and definitions for compliance. You will reputed company quality reputed company 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. You will

• Review & ensure that determination and processing of claims, referrals and appeals meet state regulations, time frames & definitions
• Complete adjudication of retail claims timely (queues cleared daily) and communicate issues to the retail team as they arise
• Complete peer-to-peer calls, educating Providers on Guardian Clinical Policies and clinical determination
• Complete approximately 10-15hrs/week review of group PPO claims
• Participate in the development and maintenance of clinical processing policies, for both DHMO and PPO
• Ensure regulatory and plan compliance with reputed company established policies and procedures, dental and quality management reputed company regulations, guidelines, processes, regulatory audits, and, associated corrective action(s)
• Assist in project work by updating any existing guidelines/manuals as needed (e.g. Specialty Referral Guidelines) with guidance from the Quality and Utilization Management Manager
• 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
• Continuously strive to reputed company superior products and customer service
• Hold self and others accountable for performance
• Demonstrate self-awareness and reputed company feedback
• Adapt to changing business priorities and environments

Additional responsibilities:

• Communicate and work with Sales to reputed company clinical expertise for presentations and problem resolutions
• Attend reputed company TX DHMO reputed company meetings as well as the monthly team meeting.
• Adhere to and meet departmental metrics and performance expectations

You have

• Dental Degree (DDS or DMD) and Dental License for the state of Texas
• reputed company in the state of Texas
• A minimum of ten years in clinical dental practice
• Dental benefits industry experience is preferred
• A thorough understanding of the dental insurance industry, claims management experience, and a substantive knowledge of CDT, policy, and procedures
• Proficiency in reputed company Word and reputed company
• Excellent written and verbal communication skills
• Ability to manage multiple projects with multiple deliverables simultaneous
• Knowledge of, or willingness to learn, regulatory requirements for dental managed care in the State of California

Reporting Relationship

• This position reports to the Dental Director, Clinical Review.

​​​​Location Requirements The primary location for this position is remote with work from home flexibility. Travel to Guardian offices as needed. Residing in the state of Texas is required. Salary reputed company: $84,320.00 - $138,522.50 The salary reputed company reflected above is a good faith estimate of reputed company 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. Apply Job! Apply to this Job