JOB DESCRIPTION

The Manager of Clinical Quality and G&A Review is responsible for overseeing the day-to-day operations of the clinical appeal review process, and performing activities that evaluate and improve the quality and safety of care and services. This individual will also assist in the design and implementation of quality improvement initiatives in support of the strategic objectives of the organization.

RESPONSIBILITIES

• Responsible for the operational execution of clinical quality management (QM) activities and appeal day-to-day operations; guides Clinical QM/G&A units to meet and exceed department quality, compliance, timeliness and production goals.
• Provides overall clinical leadership and governance for the Grievance & Appeals (G&A) Department, ensuring all clinical reviews are conducted in accordance with regulatory standards and organizational policies ensuring consistent application of plan policies and contractual requirements.
• Oversee monitoring and reporting as required by regulation or contract; Identifies provider trends discovered through PQI, PQR and G&A case review.
• Analyzes clinical trends and outcomes to identify emerging risks, assesses potential quality concerns, and uncover opportunities for process improvement, while driving strategic initiatives across internal teams and cross-functional partners.
• Identifies potential quality risks or opportunities for process improvement and implements appropriate courses of action.
• Serves as clinical subject matter expert, providing guidance to internal stakeholders and collaborating cross-functionally to deliver processes procedures, and systemic training opportunities and efficiencies to support QM and appeal team members.
• Develops P&Ps, workflows and required documents to meet federal and state regulatory requirements.
• Oversees health promotion and quality initiatives.
• Acts as educator and resource to departments in matters of health care quality.
• This list is not all-inclusive and you are expected to perform other duties as requested or assigned.

QUALIFICATIONS

• 8+ years w/Bachelor's degree; 1+ years supervisory/management
• 2-3 years' experience Quality Management Review, Denial Management, Case Management, or related experience, including leadership in a clinical operational area
• Minimum 5 years' experience in health insurance
• Excellent organizational and time management skills, with the ability to meet strict internal and regulatory deadlines with highly confidential information.
• Ability to establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.
• Excellent written, verbal, and electronic communication skills.
• Strong critical thinking, problem-solving, and decision‐making/resolution skills.
• Excellent team building, training, and leadership skills.
• Intermediate knowledge of Microsoft Office programs including Word, Excel, and Outlook.

Licenses

• Unrestricted California Dental License Required

• Certified Project Management Professional (PMP)-PMI. Preferred

• Six Sigma Green Belt Certification. Preferred

Base Pay Information

The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.
Pay Grade 22. $93,445.00 - $202,465.00.

ADDITIONAL INFORMATION

Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:

• Competitive base and incentive pay
• 401(k) with robust matching and non-matching contributions
• Rich medical & pharmacy benefits
• 100% employer-paid dental and vision benefits
• Holistic wellbeing program with deep financial incentives
• Generous paid time off plus 12 paid holidays and your birthday off
• Culture of growth and learning: career development; tuition reimbursement; recognition program
• Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
• Social responsibility and volunteer opportunities
• Employee discount program

Fair Chance Ordinances and Criminal Background Considerations

This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A.

Important Work Authorization Information

Please note, Delta Dental will not sponsor applicants for work visas for this position.

#LI-Hybrid

ABOUT THE TEAM

At Delta Dental, we're behind millions of smiles and counting. For over 68 years, we've served our communities by increasing access to affordable, quality care - but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building fair programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all.

We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie.

Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media. Follow Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn. If you've got an appetite for innovation and want to be a part of a team that's transforming the future of health care, join us!

Since 1955, we have offered comprehensive, high-quality oral health care benefits to millions of enrollees and built the strongest network of dental providers in the country. The Delta Dental of California network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico and the Virgin Islands.

The company and its affiliates are part of Delta Dental Plans Association (DDPA), a not-for-profit national association based in Oak Brook, Illinois. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company.

Delta Dental Ins. is an equal opportunity employer and is committed to providing a professional work environment free from discrimination and harassment. Individuals seeking employment at Delta Dental are considered without regard to race, ethnicity, color, age, sex, religion, national origin, ancestry, pregnancy, sexual orientation, gender identity, gender expression, genetic information, actual or perceived physical or mental disability, registered domestic partner status, caregiver status, marital status, veteran or military status, citizenship status, or any other legally protected category. Delta Dental is committed to providing equal employment opportunities to all employees and applicants for employment. Accordingly, we have adopted and maintain an Equal Employment Opportunity Policy, Harassment-Free Work Environment Policy, and Respectful Workplace policies and will not tolerate violations of these policies.

Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico, District of Columbia (Washington D.C.) or other US Territories at this time.

Proof of eligibility to work in the United States must be provided if selected for hire.

• Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York