Dental Clinical Appeals Associate Director - Central Or Eastern Time Zones

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The Dental Clinical Appeals Associate Director will support Dental Appeals and Grievances by performing clinical review of member records, performing medical necessity review, providing clinical support to resolve dental appeals and grievances following established Company policies and review criteria.

If you are located within Central or Eastern Time Zones, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Perform individual case review for appeals and grievances. The Appeals are in response to adverse determinations for dental services related to benefit design and coverage, medical necessity and the application of clinical criteria and dental policies, the Clinical Grievances are related to the quality of care provided by contracted dentists
• Communicate with other dental reviewer or director regarding appeals and grievances for recommendation rationales and benefit interpretations
• Help develop policies and procedures related to Appeals and Grievances by providing clinical and strategic input
• Resolve Clinical Appeals and Grievances disputes with dental providers, to include:
  • Claims adjudication through the Appeals processes
  • Quality of Care/Service complaints
• Generate management reports on key activities; provide clinical support to the team in producing presentations and reports
• Assist with special Appeals and Grievances projects as directed, to include:
  • Develop, implement, and monitor Quality Improvement programs
  • Improve the health of membership
  • Ensure compliance with state-specific quality requirements
  • Participate in Quality Assurance Operations, i.e. credentialing, access, peer review
  • Present as the dental subject matter expert during state Fair Hearing trials
  • Support the Health Plan regarding oral health with practical clinical and dental expertise as needed
• Participate in Quality Assurance Committees as assigned
• Interact with internal stakeholders regarding Appeals and grievances matters
• Participate in peer-to-peer calls with dental providers where required

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Dental degree from an accredited Dental School
• Active and unrestricted dental license for state of residence
• 5+ years of experience in dental practice
• 3+ years dental benefit plan experience with specific exposure to claim review and utilization management or comparable experience
• Experience with Fraud, Waste and Abuse investigations
• Demonstrated experience with managed care principles, models, and financing
• Comprehensive knowledge of Utilization Review
• Proficient PC skills including PowerPoint, Excel
• Demonstrated excellent business analytical, verbal, and writing skills
• Located in Eastern or Central Time zone

Preferred Qualifications:

• 5+ years of management level experience
• 5+ years of dental benefit plan experience
• Reside in the state of Missouri and maintain an active Missouri state dental license

Connecticut, New Jersey, New York or Rhode Island Residents Only: The salary range for Connecticut, New Jersey, New York or Rhode Island residents is $104,700 to $190,400 annually. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.