Clinical Quality Specialist

Delta Dental of Minnesota; Minneapolis (MN); On-site; USD 83,000 - 104,000; Full time

Job summary

An established industry player is seeking a Compliance Manager to oversee quality improvement and compliance activities in the dental benefits sector. This role involves managing the Quality Improvement Program, coordinating Utilization Management, and ensuring adherence to regulatory standards. The ideal candidate will possess a strong understanding of the health insurance industry and demonstrate exceptional problem-solving and communication skills. Join a top workplace that values professional growth and innovation, and make a significant impact on the quality of dental care for millions of members.

Benefits

Medical, dental, and vision insurance

Life insurance

Disability coverage

401(k) plan

Paid Time Off (PTO)

Holidays and days of remembrance

Qualifications

• Broad knowledge of health insurance and state regulations.
• Experience in credentialing and quality assurance is essential.

Responsibilities

• Manage compliance and quality improvement activities for dental practices.
• Coordinate activities for Utilization Management and conduct audits.
• Foster relationships to support program innovation and growth.

Skills

Knowledge of health insurance industry

Credentialing experience

Grievance resolution

Quality assurance

Strong communication skills

Problem-solving skills

Ability to multi-task

Education

RDH with clinical experience

Bachelor's or Master's degree

Tools

Microsoft Office

Job description

Delta Dental of Minnesota is proud to be the largest regional provider of dental benefits, serving over 7,000 Minnesota and North Dakota-based purchasing groups and 4.5 million members nationwide. We aim to provide a work environment that engages each individual while encouraging growth and professional development. We are proud to be named a Top Workplace employer for several years and take pride in our team members for building this reputation.

GENERAL SUMMARY

This position is responsible for assuring provider compliance and managing quality improvement activities for commercial business, Medicaid, and Medicare. Management of the compliance program includes prevention, detection, and resolution of erroneous or fraudulent billing practices, directing activities of the utilization management program, conducting compliance audits of dental practices, monitoring contract and policy compliance, providing training to Delta Dental of MN employees, and coordination of compliance activities with clients and appropriate governmental and law enforcement agencies.

ESSENTIAL FUNCTIONS

1. Manage the Quality Improvement (QI) Program. Review the plan annually and prepare document updates for the PRRC. Implement and monitor the annual QI Plan. Prepare reports and responses for proposals. Work with health plans to support their respective QI activities. Responsible for working collaboratively with internal management in setting direction and strategic planning to develop, implement, and monitor action plans to achieve overall QI program success.
2. Align and coordinate the work within the Professional Relations and Operations department specific to HEDIS data analysis, Data Analytics and Reporting, Regulatory Adherence, and oversight to compliance with CMS requirements.
3. Form internal and external strategic relationships which will support program innovation, growth, expansion, and the development of new programs that will enhance QI activities.
4. Foster innovative problem-solving and uphold principles of continuous quality improvement.
5. Coordinate activities for the Utilization Management (UM) program. This includes reviewing fraud, waste, and abuse analytical reports, managing the fraud hotline, conducting audits of dental practices (desk and on-site), providing training to Delta Dental employees, coordinating committee meetings, and reviewing the UM plan document annually.
6. Coordinate fund recovery with legal and finance departments. Ensure appropriate organizations are informed of audit findings as appropriate.
7. Manage credentialing activities to include participation on the Credentialing Committee, preparation of cases for review by the Professional Relations & Review Committee, preparing letters to providers, assisting legal counsel with attorney review, oversight of terminations, and reports to regulatory agencies and health plans. Manage processes to receive voluntary terminations and work with Provider Services to establish protocols and policies for retention.
8. Attend external fraud-related meetings and conferences to increase knowledge and experience. Represent Delta Dental of MN at compliance meetings and provide reports as required.
9. Research and review quality-of-care member grievances. Report and track findings. Prepare responses to members and providers. Analyze grievances to determine trends that may inform quality improvement activities.
10. Participate in the process of securing regulatory or health plan approval, as appropriate. Utilize corporate legal staff to file and review documents and secure approval from appropriate agencies. Assist in the response, with legal staff, to inquiries from regulatory agencies or health plans as needed. Assess the impact of legislation on the provider contracts and suggest adjustments to legal staff as appropriate.
11. Continuously review, audit, and manage an ongoing process that ensures contract requirements are properly implemented and functioning as designed. Analyze, document, and communicate identified issues to develop solutions that can be successfully implemented. Ensure a focus on implementing process improvements on a continuing basis.
12. Provide clinical expertise to internal and external audiences. Prepare newsletter articles, marketing materials, provider information, presentations, and other supporting documents as requested to educate and promote oral health and overall health.
13. Support compliance activities for Delta Dental Plans Association to include directory accuracy, CDT code updates, provider processing policies, credentialing requirements, and compliance with claims adjudication.
14. Participate in special projects, as directed by the Vice President of Dental Services.

This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the team member. Duties, responsibilities, and activities may change or be assigned at any time without notice.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

1. Broad knowledge of the health insurance industry, including healthcare delivery systems, insurance concepts, and state and federal insurance regulations.
2. Experience with credentialing, grievance resolution, and quality assurance.
3. This position requires a self-starter who is comfortable working with minimal supervision.
4. Strong written and oral communication skills.
5. Proficiency in Microsoft Office, including Word, Excel, and PowerPoint, with the ability to work with software programs specific to the operational management of business.
6. Ability to multi-task and meet required deadlines.
7. Strong problem-solving skills.
8. Proven ability to exercise good judgment and make independent decisions. Ability to exercise tact and diplomacy.

REQUIRED EDUCATION AND EXPERIENCE

1. RDH with clinical experience is required.
2. Bachelor's or Master's degree desired.

WORK ENVIRONMENT/PHYSICAL DEMANDS

1. Travel Requirements: Minimal.
2. Weight Lifting Requirements: 20 lbs. or less.

RELATIONSHIPS

1. Reports To: Vice President of Dental Services.
2. Directly Manages: n/a.
3. Internal Relationships: Operations, Actuarial, Marketing, Account Management, Legal, and the Delta Dental Foundation.
4. External Relationships: Includes, but is not limited to, providers, clients, government entities, and other stakeholders with interests in the dental industry. This position will work closely with a third party who provides support and services to the grievance and appeal process.

BENEFITS AND COMPENSATION

Benefits for this position include medical, dental, vision, and life insurance; disability coverage; flexible spending plans; a 401 (k) plan; Paid Time Off (PTO); and Holidays and days of remembrance. Visit http://www.deltadentalmn.org/employee-benefit-packages for more information.

The starting salary range for this position is $83,000.00 to $103,750.00. Salary offers will typically be made in the listed range. The Company takes into consideration a candidate's education, training, and experience, as well as the position's work location, expected quality and quantity of work, required travel (if any), external market and internal value, including merit process and internal pay alignment when determining the salary of potential new team members. In compliance with state and federal regulations, a potential new team member's salary history will not be used in compensation decisions.

EQUAL EMPLOYMENT OPPORTUNITY (EEO) STATEMENT

Equal Opportunity Employer / Protected Veterans/ Individual with Disabilities.

The contractor will not discharge or, in any other manner, discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to an individual who do not otherwise have access to compensation information unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. CFR 60-1/35(c)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)