POSITION SUMMARY

Provides vision, leadership, and management of Hawaii Dental Service’s (HDS) interactions with the dental provider community (including Medicare and Medicaid dental providers) and State of Hawaii MedQUEST Division. Serves as the clinical dentistry expert for HDS and MedQuest Division and is the primary liaison with the dental profession representing the professional dental viewpoint. Executes clinical review of claims consistent with HDS, Medicare, Supplemental Medicaid, and MedQUEST policies and contracts. Directs the activities of the Dental Consultants Department and utilization management, supervises staff, and coordinates activities with other departments. Represents HDS in national and Delta member company lead initiatives. Identifies emerging technologies and trends in the dental industry and provides analysis and recommendations to HDS. Dental Director is a clinician and administrative leader.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

• Directs staff in utilization management and developing and interpreting claims processing policies and adjudicates claim and benefit review requests.
• Provides input and support for dental product development and improvements/modifications to reflect best findings from clinical practice, dental research, and outcome data.
• Reviews and adjudicates preauthorizations, claims for service, and reconsideration requests in accordance with appropriate HDS, MedQUEST, and other guidelines. 
• Reviews and processes all Medicaid requests for Hospitalization and Medical Anesthesia for dental services and Orthodontics in compliance with State of Hawaii MedQUEST policies while maintaining close communication with the respective dental provider(s).
• Develop, revise and implement new benefit procedure codes and their associated clinical policies for both commercial, Medicare, and Medicaid businesses.
• Provide timely clinical dentistry guidance and professional advice to the State of Hawaii MedQUEST Division on specific clinical and patient care issues, clinical policies, and other issues that may arise.

• Communicates and assures that employees have a clear understanding of performance expectations and responsibilities. Provides direction to staff as necessary. Continuously raises expectations and performance levels without sacrificing procedural and data integrity.
• Provides training for utilization management and HDS claims adjudication and customer service staff on clinical, policy, and processing topics.
• Assists the Compliance and Government Programs departments to provide clinical analysis for dentist office reviews. Presents clinical results as necessary to senior management, the HDS Quality Committee, and the HDS Board of Directors.

• Supervisory
  • Supervises/Manages the following staff: 3 Dental Consultants and 1 Utilization Management staff. Manages, plans, organizes, supervises, trains, motivates, and evaluates staff; including making final hiring & termination decisions, assigning work, developing growth opportunities, conducting performance evaluations, and taking corrective action. Communicates and assures that employees have a clear understanding of performance expectations and responsibilities. Plans, directs, and manages towards effective and appropriate activities and ensures the satisfactory performance of those employees.
• Budget
  • Develops and manages the department’s annual budget in alignment with company goals and objectives.
• Business Plan/Establish Departmental Goals.
  • Develops and maintains departmental performance measures and standards.
• Policies/Procedures.
  • Determines policy for benefit review procedures. Determines dental necessity and appropriateness of treatment regimens. Updates the HDS Procedure Code Guidelines.

Other Duties and Responsibilities

• Customer Service (Internal/External)
  • Plans, directs, and manages the activities related to the department. Monitors productivity and performance while ensuring professionalism, quality, timeliness, and accuracy in accordance with overall company-wide objectives to ensure positive working relationships with internal and external customers.
  • Communicates with individual dentists to explain HDS, MedQUEST, and other dental policies, answers claims questions, and counsels dentists on inappropriate practice patterns.
  • Conducts presentations for dentists and dental office staff covering HDS policies, clinical topics, and other subjects of interest to the dental community.
• Identifies emerging technologies and trends in the dental industry and provides analysis and recommendations to the senior management team.
• Advises the organization’s senior management team, Board of Directors, and other department managers and staff on dental policy and clinical matters.
• Serves as a liaison with the dental profession and represents the professional dental viewpoint; as a local provider liaison/advocate between HDS and MedQUEST.
• Represents HDS at dental consultant conferences and meetings.
• Provides input and recommendations for provider reimbursement fee adjustments.
• Conducts presentations for HDS groups on oral health topics.
• Performs other related duties as required or assigned by the Chief Operating Officer
• May perform routine administrative tasks as needed.

MINIMUM QUALIFICATIONS AND EXPERIENCE

Education

D.D.S. degree from an accredited university. Licensed to practice in the State of Hawaii.

Experience

• Minimum of 5 -10 years professional/management level experience in the accepted standards of dental treatment, including developments in dental materials and treatment modalities. Prefer previous experience in dental private practice, knowledge, and experience in processing dental claims, and prior dental consultant experience.
• Minimum of 5 years of experience managing/supervision of staff. Well-versed in the accepted standards of dental treatment, including developments in dental materials and treatment modalities.
• Knowledge of modern dental science practices, utilization review techniques, data/ statistical analysis, practice protocols, and ADA issues.
• Strong skills, abilities, and commitment to teamwork.

Skills and Knowledge

• Established relationships with organized dentistry and dental schools, a recognized leadership role in the Hawaii dental community.
• Familiarity with dental quality assurance programs.
• Ability to analyze complex topics or issues and effectively resolve problems.
• Ability to handle multiple tasks and prioritize with some distractions and attention to details and produce expected outcomes.
• Ability to maintain confidential material in compliance with HDS policies and federal/state laws.
• Technical knowledge to understand computer applications for claims processing and problem-solving (prefer Windows, Word, Excel, and PowerPoint).
• Duties require the use of considerable initiative, leadership skills, creativity, judgment, problem-solving, and working under minimal or no supervision. 
• Requires working under frequent deadlines or pressure; dealing with difficult people or situations involving complex issues; and negotiating, establishing, and maintaining cooperative and productive business and work relationships.
• Requires communicating effectively both orally and in writing; giving instructions or directives to others; all levels of staff, customers, consultants/brokers, and vendors on sensitive matters; and seeking information from a variety of sources.
• Ability to express ideas clearly and concisely; make effective presentations, interact effectively with people in all functions of HDS, both internally and externally. 
• Requires analyzing complex topics or issues and effectively dealing with the public.

Note: The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.