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Job Purpose and Summary:
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The Dental Director - Medicare Appeals is an individual contributor who will assure that members receive quality dental care and improve population oral health.
Primary Job Duties & Responsibilities:
- Utilizes clinical experience and skills in a collaborative process to assess appropriateness of dental treatment, and to apply evidence based standards and practice guidelines as appropriate
- Using clinical information and documentation, applies the appropriate clinical criteria, guideline, policies, and clinical judgment to render claim/appeal adjudication determinations
- Participates in Aetna Quality Management processes, including credentialing, site assessments, peer review, complaints, grievances and appeals (CGA)
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization management and CGA functions
- DDS or DMD and a valid state license to practice dentistry
- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
- Basic knowledge of dental benefit products and platforms (DMO, PPO, Medicare Advantage)
- Strong understanding of clinical quality programs, and clinical integration
- Financial acumen, coupled with strong problem solving and analytical abilities
- Excellent written and verbal communication skills
- Familiar with federal and state regulatory bodies such as CMS and the CA Department of Managed Health Care
- 5 years of experience in dental clinical practice
The typical pay range for this role is:
$123,857.50 - $266,770.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit Benefits | CVS Health
We anticipate the application window for this opening will close on: 12/31/2024
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.