The Manager, Professional Services leads and manages the Professional Services (Review) Team. This position is responsible for oversight of tasks involving dental consultant review; appeals and grievances; and fraud, waste, and abuse. The manager understands and upholds DDPA requirements and works with other member company representatives in resolving National Provider File-related claim issues.
Responsibilities •Manage the dental consultant claim review process; analyze and report claim cost containment and other metrics •Implement and maintain utilization review programs as well as fraud, abuse, and waste detection and resolution initiatives •Recognize, investigate, and resolve dentist contract non-compliance as it relates to dental claims •Monitor DeltaUSA Processing Policy compliance: understand and communicate policies to internal and external contacts •Provide claim resolution with and for other Delta Dental member companies using National Provider File (NPF) data •Manage resolution of issues with groups, agents, dentists, dental office staff, and internal customers •Understand and promote the use of electronic data solutions internally and externally •Oversee the grievance process, including tracking and reporting •Develop key metrics and monitor production requirements, turnaround times and workflow fluctuations •Conduct performance evaluation of staff and provide feedback and coaching to team members •Initiate process improvement measures and ensure documentation of processes and procedures •Communicate key messages to staff; schedule and facilitate department meetings •Actively participate in Operations Team Leader weekly meetings and Managers and Directors monthly meetings •Assist the Director, Professional Services with budget development and strategic planning •Special projects and duties as assigned
•Requires a bachelor’s degree in business or related field and three years’ experience or equivalent combination •Three years of business related experience including training, managerial and direct supervisor responsibility •Three to five years of clinical chairside dental experience •Previous insurance business experience on either the payer or provider side •Computer skills, including experience with MS Office Suite applications •Strong interpersonal, written and oral communication skills •Analytical and problem-solving abilities •Ability to effectively prioritize and execute tasks •Must be well-organized and attentive to detail •Strong customer service orientation; ability to handle escalated or more technically complex telephone calls •Experience working in a team-oriented, collaborative environment •Ability to operate a computer keyboard, mouse, and other office equipment
Internal Number: Mgr, Professional Service
About Delta Dental of Wisconsin
Delta Dental of Wisconsin, Inc. is a not-for-profit dental service corporation offering benefit services, claims processing, and plan administration to employers throughout Wisconsin since 1962. The company is headquartered in Stevens Point, with sales offices in Milwaukee and Madison, and provides benefits and services to more than 1.4 million subscribers and their family members. Delta Dental administers dental benefits for more Wisconsin companies than any other insurance carrier. As a member of the nationwide Delta Dental Plans Association, the company is able to offer the same dental benefits to all employees of Wisconsin-based companies wherever they are located in the United States. The Delta Dental Plans Association is the largest dental benefits system in the nation. Its member companies provide benefits to over 51 million people in 93,000 groups across the United States. Visit us online: Blog - http://blog.deltadentalwi.com/ Facebook - https://www.facebook.com/DeltaDentalWI Twitter - https://twitter.com/DeltaDentalWI Google+ - https://plus.google.com/b/112127418627107201222 YouTube - https://www.youtube.com/user/DDofWI/ We are an Equal Opportunity Employer.