Job Summary:

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities for all. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It's a mindset, feeling and attitude we wrap around all that we do -- from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description

Plans, organizes, and oversees the administrative and technical functions of the Government Programs Prior Authorization team to ensure corporate and departmental goals and objectives are met.

Primary Job Responsibilities

Manages the administrative and technical functions of the Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes) teams to ensure achievement of corporate strategies, goals, and objectives. 

Manages and administers all Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes) processes for Government Programs business as assigned. 

Oversees Government Programs Prior Authorization and Provider Appeals (reconsiderations/provider claim disputes); creates, defines, and enforces procedures and processes to ensure claims are processed timely and accurately; ensures new business rules/claim routes are implemented, claim processing guidelines updated, and claims processed appropriately; and develops and prepares departmental reports and analyzes business processes and information. 

Oversees and ensures strict adherence to regulatory requirements for Government Program Prior Authorizations and Provider Appeals (reconsiderations/provider claim disputes); defines and enforces processes and procedures to ensure claims processing timeliness and accuracy; ensures new regulatory requirements are implemented and met accordingly; and develops and prepares departmental reports and analyzes business processes and information including, but not limited to timeliness, processing accuracy, and reporting requirements.  

Manages the Provider Appeals (reconsiderations/provider claim disputes) process to ensure cases are completed within timeliness requirements; creates and monitors reports for priority groups and government program oversight.

Serves as a subject matter expert for claims processing questions as it relates to Government Programs Prior Authorizations, Provider Appeals (reconsiderations/provider claim disputes), DeltaUSA processing policies, contractual limitations, and government program requirements.

Interviews, hires, trains, mentors, evaluates, and develops staff to ensure accountability for achievement of corporate, departmental, and individual goals and objectives.

Trains staff and performs accuracy reviews of claims processed to ensure timeliness and accurate claims adjudication pursuant to departmental guidelines/standards, DeltaUSA processing policies, client contracts, provider agreements, state/federal laws, and government program requirements. 

Acts as a resource for staff and manages and maintains relationships with internal departments, committees, affiliates, and other various external customers to provide dental expertise and/or interpretation of dental policies, procedure codes and processing guidelines in the areas of Government Programs Prior Authorization, Provider Appeals (reconsiderations/provider claim disputes), benefits questions, and rule-based routing exceptions. 

Develops, monitors, and maintains monthly work list and individual production and qual