Dental Policy & Quality Manager

This is a fully remote position, open to applicants in Kansas.

📋 Description

• Take ownership of the development, documentation, and ongoing maintenance of G.E.H.A.'s dental coverage policies, benefit criteria, code-level guidance, annual CDT updates, and version-controlled policy library.

• Lead the initial policy audit and realignment initiative.

• Act as G.E.H.A.'s authoritative figure on dental policy and coding for TPA and clinical review vendor alignment, OPM filings, benefit reviews, member escalations, audit findings, and coverage interpretation.

• Manage the annual BENEFEDS CDT reporting process in collaboration with TPA and Data & Analytics.

• Chair the clinical policy review process involving actuarial, compliance, legal, network, and operations stakeholders.

• Set clinical evidence standards and documentation protocols to support defensible coverage positions.

• Provide dental clinical content and review educational materials for members and providers.

• Simplify complex coverage policies, clinical criteria, and coding requirements for various audiences.

• Offer dental policy and coding expertise to Network Oversight.

• Represent the clinical side in escalated provider disputes.

• Manage the contract and daily relationship with the clinical review vendor, covering renewals, invoicing, SLA compliance, performance documentation, and audit-ready records.

• Oversee vendor performance, ensuring consistency in determinations, clinical accuracy, turnaround compliance, and documentation quality.

• Direct vendor governance regarding workflow, case routing, quality reviews, policy alignment corrections, updated review criteria, and corrective action plans.

• Represent G.E.H.A. during OPM audits, site visits, and regulatory inquiries.

• Provide leadership with advice on regulatory and financial exposure, recommending mitigation strategies.

• Conduct root-cause analyses and remediation for claims payment errors driven by policy issues.

• Ensure that clinical policy documentation meets evidentiary standards for OPM audits, appeals, and external challenges.

• Offer technical direction and clinical guidance to external clinical reviewers.

• Mentor and develop internal staff on dental benefit interpretation, CDT coding, and clinical policy reasoning.

• Serve as the point of escalation for complex clinical coverage inquiries, coding disputes, and methodology disagreements.

• Establish quality standards and review protocols for dental clinical policy and coding tasks.

⛳️ Requirements

• A Bachelor's degree in Dental Hygiene, Health Administration, Health Informatics, or a related field is required; an advanced degree is preferred.

• Dental clinical training, licensure, or certification (RDH, DDS, or equivalent) is required, or equivalent clinical depth gained through extensive dental utilization management or clinical policy practice.

• A comprehensive working knowledge of dental procedures, CDT coding, and clinical benefit criteria is essential.

• Additional relevant work experience may be considered in lieu of formal education.

• A minimum of 10 years of progressive experience in dental benefits, dental policy development, dental utilization management, or managed dental care is required.

• At least 3 years of experience in a lead or functional authority role.

• In-depth subject matter expertise in dental benefit policy, CDT codes, ADA coding guidelines, and dental benefit structures is required.

• Experience in monitoring, assessing, and implementing annual CDT code updates within a health plan environment is necessary.

• Direct experience in developing or maintaining dental coverage policies in a health plan, TPA, or managed care setting is essential.

• Experience collaborating with TPAs or clinical review vendors on policy alignment, adjudication accuracy, and contract performance oversight is required.

• Experience in establishing clinical policy governance processes, leading clinical policy review forums, or providing technical direction to clinical professionals is advantageous.

• A working knowledge of health plan regulatory, compliance, audit, and documentation requirements is essential.

• The ability to apply regulatory expectations to benefit policy development, coverage criteria, vendor oversight, appeals support, and audit readiness is required.

• Strong clinical reasoning skills to evaluate dental necessity, appropriateness, and evidence quality are necessary.

• Excellent written communication skills are a must.

• An analytical and detail-oriented mindset is essential.

• A collaborative and cross-functional working style is required.

• Self-directed and accountable, with project management capabilities.

• Proficiency in Microsoft Office Suite is needed.

• Experience with policy management tools, content management systems, or SharePoint is preferred.

• Familiarity with BENEFEDS, FEDVIP, or OPM-regulated dental benefit programs is a significant advantage.

• Experience in developing educational content for members or providers is preferred.

• Knowledge of dental utilization patterns, post-payment audit findings, or claims data analysis is preferred.

• Ability to provide non-cellular high-speed internet service such as fiber, DSL, or cable modem for a home office is essential.

• Minimum internet speed of 30 Mbps download and 5 Mbps upload is required.

• Latency response time should be lower than 80 ms.

• Hotspots, satellite, and wireless internet service are not permitted.

• A dedicated workspace without ongoing interruptions is necessary to protect member PHI/HIPAA information.

🏝️ Benefits

• Competitive pay/salary ranges.

• Incentive plan available.

• Health, Vision, and Dental benefits effective from day one.

• 401(k) retirement plan with a company match of dollar for dollar up to 4% employee contribution (including pretax or Roth options) plus a 6% annual company contribution.

• Comprehensive employee well-being program.

• Paid Time Off (PTO).

• Personal Community Enrichment Time.

• Company-provided Basic Life and AD&D coverage.

• Company-provided Short-Term & Long-Term Disability benefits.

• Tuition Assistance Program available.

• Remote work opportunities.

• Hybrid and work-from-home options available for many roles.