TMF Health Quality Institute and C2C Innovative Solutions, Inc. are Equal Opportunity Employers (Minorities/Females/Vet/Disability)

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2017:86: Associate Dental Director (AMD)
Position Code:2017:86
Team:Medical Affairs
Location:Texas (Remote)
  
Job Responsibilities:

Position Purpose:
Performs highly advanced (senior-level) work.  Applies clinical decision making skills in determining medical necessity.  Serves as a clinical expert in special projects and policy development, as needed.  Works under minimal supervision, with considerable latitude for the use of initiative and independent judgement.

Essential Responsibilities:
· Applies expertise in the review of prior authorization requests within limits of Medicaid program and medical/dental policy.
· Enters prior authorization determinations accurately in the software application, including providing clear and careful documentation for the rationale for medical necessity determination.  Documentation must facilitate preparation of notification letters for providers and clients.
· Provides clinical expertise to medical staff on craniofacial or other issues as requested.
· Provides clinical expertise to nurses performing prepayment and retrospective review.
· Assists in developing and completing educational updates for the dental staff as requested.
· Assists in Texas Medicaid policy development as requested.
· Evaluates healthcare utilization to ensure resources are properly used.
· Appropriately and accurately applies Texas Medicaid policies to prior authorization requests, prepayment review and retrospective review.
· Maintains professional licensure and education in field of expertise to ensure knowledge base remains current.
· Participates in special projects and performs other duties as assigned.

Job Qualifications:

Minimum Qualifications
 
Education
• Graduate of an accredited dental school

License and Certification
• Doctor of Dental Medicine or Dental Surgery with an active license by the Texas State Board of Dental Examiners
• Special orthodontia training or Orthodontist with active Board Certification, preferred

Experience
• Seven (7) years of experience in the delivery and management of dental care
• Medical/Dental Record Review, Utilization Review, or Prior Authorization, preferred

Knowledge, Skills and Abilities

Extensive Knowledge of
• Current diagnostic and service code sets
• Dental methods, procedures, and trends
• Principles and practices in the development, implementation, and documentation of individualized care and treatment plans
• Applicable laws, rules and regulations

Working Knowledge of
• Medicaid and/or Children’s with Special Healthcare Needs program rules
• Principles of public health practices
• Practices of clinical or public administration and management

Expert Skill in
• Care and treatment of patients
• Developing, describing, and communicating dental processes and procedures
• Problem identification, analysis, and resolution
• Researching, analyzing and interpreting policies and state and federal laws and regulations
• The use of personal computers and applicable programs, applications and systems

Ability to
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assure compliance with regulatory, contractual and accreditation entries

Work Environment
Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry or move up to 25 lbs. when transporting work equipment or materials.  May require ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.