Position Summary: 

The Dental Consultant is responsible for participating in Utilization Management for Delta Dental of Virginia and works closely with the Professional Review staff, Dental Director and Chief Dental Officer. This position is focused on claims review and will partner with the Dental Director. This position assists in developing dental policy and procedures consistent with Delta Dental’s mission to ensure a competitive position for the company.

Essential Functions:

The Dental Consultant is responsible for providing leadership and coordination of efforts between departments in the following activities as they related to Delta Dental of Virginia.

• Claims Administration responsibility for:
  1. The determination of dental necessity and appropriateness of treatment standards, primarily as it relates to the review of dental claims. This includes assisting in the development of dental policy and staff and/or vendor calibration practices.
  2. Providing input on policy for efficient and effective benefit review processes which assure the compliance of providers and subscribers with the provisions of employer dental contracts.
  3. Providing recommendations to the Professional Review staff specific to claims determinations and interpretation of dental policy.

• Adjudicate special claims and benefit review requests in a timely manner. Administer other dental related issues impacted by Delta Dental’s policies or procedures.
• Responsible for the timely and accurate review of claims to achieve cycle-time and accuracy standards.
• Communicates with dental care providers as requested, regarding claim and benefit matters to resolve disputes on individual claims.
• May perform other functions as assigned.

Qualifications/Education/Experience:

• A degree from an accredited U.S. College of Dentistry (DMD or DDS) with a current dental license or eligibility for Virginia license to practice dentistry.
• Minimum of 5 years dental practice experience; two or more years of dental consulting experience is preferred and clean malpractice history.
• Evidence of regular Continuing Education course completion.
• Administrative or management experience preferred.
• Familiarity with current dental science, utilization review techniques, data/statistical analysis, practice protocols and ADA issues; ability to analyze data and make effective decisions; knowledge and understanding of healthcare insurance products, dental industry trends, and the administrative delivery of group products desirable.
• Ability to think and plan strategically for organizational success.
• Strong interpersonal and communication skills.