Director, Professional Review and Utilization Management

Delta Dental; Naperville (IL); Hybrid; USD 175,000 - 200,000; Full time

Benefits offered by this job

Free dental coverage for employees and

Free vision coverage

Life insurance

Short-term disability

Long-term disability

Medical plan options

401(k) with company match

Generous paid time off

11 paid holidays per year

Hybrid work schedule

Job summary

Delta Dental of Illinois is seeking a Director, Professional Review & Utilization Management to lead dental consultants and oversee clinical reviews and appeals in Naperville, IL. The role drives policy consistency, data-driven decisions, and quality assurance across utilization management activities.

You will manage review vendors, guide policy interpretation with cross-functional teams, and contribute to fraud and abuse investigations while supporting site reviews and performance management.

Qualifications

• DDS or DMD degree and a state dental license in good standing; Illinois licensure preferred but not required.
• At least 10 years of clinical experience and 3 years of dental consulting or professional claims review experience preferred.
• Expertise in dental benefits, industry trends, utilization review, dental policy, quality assurance, and reimbursement.
• Knowledge of dental science, review standards, data analysis, practice protocols, Current Dental Terminology (CDT), and American Dental Association (ADA) issues.
• Working knowledge of claims processing and clinical and professional review policies.
• Strong written, verbal, and interpersonal communication skills, with sound analytical and problem-solving abilities.
• Proficiency in management, budgeting, information systems, and multiple software applications.
• Ability to travel within Illinois and occasionally out of state.

Responsibilities

• Lead clinical claims reviews, including second-level determinations, in accordance with Delta Dental guidelines.
• Train, coach, and manage dental consultants; promote consistent clinical determinations through standardization exercises.
• Oversee clinical appeals and second-level dentist reviews; conduct peer-to-peer discussions with treating dentists.
• Resolve quality-of-care and treatment grievances; investigate fraud, waste, and abuse and recommend resolutions to the VP.

Skills

Leadership

Data analysis

Policy development

Communication

Budgeting

Education

DDS or DMD degree

State dental license

Tools

CDT

ADA

Job description

Director, Professional Review & Utilization ManagementBring your clinical expertise and leadership skills to Delta Dental of Illinois. As Director, Professional Review & Utilization Management, you’ll lead dental consultants, oversee clinical reviews and appeals, and strengthen policies that support consistent, appropriate benefit decisions.What You’ll DoLead clinical claims reviews, including second-level determinations, in accordance with Delta Dental guidelines.Train, coach, and manage dental consultants; promote consistent clinical determinations through standardization exercises.Oversee clinical appeals and second-level dentist reviews; conduct peer-to-peer discussions with treating dentists.Resolve quality-of-care and treatment grievances; investigate fraud, waste, and abuse and recommend resolutions to the Vice President, Dental Science & Network Strategy.Assess treatment necessity and appropriateness; answer policy inquiries and guide Professional Relations, Claims, and Customer Service on escalated clinical matters.Manage professional review vendors and monitor performance, quality, and clinical consistency.Partner with the Vice President, Dental Science & Network Strategy on review policies and utilization guidelines; support dental policy, quality management, utilization data, and peer review.Analyze utilization trends and outlier provider patterns, oversee site reviews and quality audits, and track review timeliness, accuracy, and consistency.Lead planning, budgeting, team development, and performance management; serve on assigned projects and fraud, quality, and peer review committees.What You’ll BringDDS or DMD degree and a state dental license in good standing; Illinois licensure preferred but not required.At least 10 years of clinical experience and 3 years of dental consulting or professional claims review experience preferred.Expertise in dental benefits, industry trends, utilization review, dental policy, quality assurance, and reimbursement.Knowledge of dental science, review standards, data analysis, practice protocols, Current Dental Terminology (CDT), and American Dental Association (ADA) issues.Working knowledge of claims processing and clinical and professional review policies.Strong written, verbal, and interpersonal communication skills, with sound analytical and problem-solving abilities.Proficiency in management, budgeting, information systems, and multiple software applications.Ability to travel within Illinois and occasionally out of state.Why Delta Dental of Illinois?Based in Naperville, Illinois, Delta Dental of Illinois brings more than 50 years of oral health experience and a commitment to our clients, members, employees, and communities. Through our dental benefit programs and Foundation, we help improve access to oral health care and education.We offer:Free dental coverage for employees and their dependentsCompetitive benefits, including free vision, life, and short- and long-term disability coverage; medical plan options; and a 401(k) with company matchGenerous paid time off and 11 paid holidays per calendar yearA collaborative culture and healthy work-life balanceA convenient Naperville, Illinois, location off I-88 and a hybrid work scheduleHiring base pay range of $175,000 to $200,000 plus bonus.Ready to bring your clinical expertise and collaborative leadership to this role? Apply to help shape professional review and utilization management at Delta Dental of Illinois.Delta Dental of Illinois is an equal opportunity employer.