This position oversees clinical aspects of multiple departments at Argus Dental & Vision, Inc. This is a Full Time role.
Summary of Essential Job Functions
Acts as the central point of contact for clinical insight on all dental operations decision-making needs or client escalation concerns, including tasks such as, but not limited to, utilization management medical necessity review of prior authorizations, review of denial recommendations on prior authorization, CDT code cost analysis, chart reviews, and quality reviews.
Oversees the Dental Provider Manual and Dental Clinical Guidelines construction and revisions.
Stays abreast of all industry policy and regulatory updates, writing executive summaries as needed to share with the executive team.
Participates/supports any internal dental client audits as needed.
Conducts peer to peer discussions and education with dental providers as necessary.
Reviews grievance and appeal cases as requested, including Quality of Care cases.
Participates in the grievance process, including Maximus or ALJ hearings as needed to ensure a fair member outcome.
Reviews over and underutilization and upcoding or improper coding.
Ensures provider fee schedules are constructed properly from the clinical perspective.
Chairs the Dental Peer Review Committee.
Works with the Credentialing department to oversee the credentialing of all dental providers.
Conducts provider outreach and education based off feedback from the provider and member surveys.
Writes “From the Desk of the Dental Director” columns for the provider newsletter.
Participates as a member of the Utilization Management Committee, the Health Education and Wellness Committee, Grievance and Appeals Committee, and the Quality Improvement Committee.
Assists with the investigation and write up of risk management cases.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.
Required Knowledge, Skills and Abilities
DDS/DMD degree and current state license (Florida required)
Ability to thrive in a fast-paced organizational structure.
Experience working on projects in a team-based environment.
Takes initiative and responsibility: a self-starter with a strong focus to meet deadlines and deliver results with a high attention to detail.
Proficient in MS Office software, including Outlook, Word, PowerPoint, and Excel.
Capable of identify processing deficiencies and initiate recommendations for process improvement
Exhibits a professional demeanor.
Excellent communication, interpersonal, organizational, project management and planning skills required.
Telecommuting is allowed.
Internal Number: DentalDirector20200909
About Argus Dental & Vision, Inc.
Argus Dental has built one of the largest proprietary dental networks with a national partnership in all fifty states in the United States. Our network of partnering dentists continues to grow at a rapid rate and currently offers members their choice of dentists from over 100,000 combinations of partnering general and specialty locations. Argus Dental & Vision offers the first dental plan and vision plan in the United States to be accredited for quality care by the Accreditation Association for Ambulatory Health Care (AAAHC) and is contracted with the Florida Healthy Kids Corporation to provide affordable dental care to children in Florida. All Argus dentists are credentialed in accordance with guidelines set forth by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS).
Launched in June 2013, Argus Vision provides routine and medical eye care solutions to health plans. Argus Vision is currently developing a credentialed proprietary eye care network that includes both retail optical and independent optometrist locations. Vision plans feature a flexible financial structure in accordance with specific needs including full risk and/or ASO contracting options.