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Job Purpose and Summary:

The dedication of talented and caring health care professionals drives the delivery of high quality, cost effective products and services. They make it possible for members to get the right health care treatment for their needs – and for Aetna to keep its competitive edge.

Develop, implement, support, and promote Dental Healthcare strategies, tactics, policies, and programs that drive the delivery of quality dental care to establish competitive business advantage for Aetna. Dental Healthcare strategies, policies, and programs are comprised of utilization management, quality management, oral health integration, network management and clinical coverage and policies.

Provide oversight, clinical expertise and business direction in support and in the evaluation of dental clinical policy implementation, program management, and strategic decisions to promote the delivery of high quality, constituent responsive and cost effective dental care. Serves as the Dental and business leader and contact for external providers, plan sponsors, and regulatory agencies.

This is a remote based (work from home) role and resides in New Jersey.

Primary Job Duties & Responsibilities:

* Formulate and implement strategy for the organization/unit to meet KPM's (key performance measures), expand dental programs to address member needs across the continuum of care and other strategic business initiatives

* Drive clinical innovations that integrate and connect health care data and deliver increases clinical quality

* Provide clinical expertise and business direction in support of dental programs through participation in clinical team activities and serve as technical professional and business resource

* Render consistent opinions on emerging dental trends, utilization review, dental plan coverage, network management, claims policy and standards of care and develop, implement, and evaluate policies and procedures, which meet business needs

* Use data analysis to identify opportunities for quality improvement, cost containment and to positively influence practice patterns or benefit plan designs and collaborate such with internal and external partners

* Develop and participate in presentations and consultations to existing and prospective customers

* Appropriate and timely management of predetermination, claims reviews, complex clinical complaints/appeals/special investigations providing clinical, coding, and reimbursement expertise and support staff to ensure timely and consistent responses to members and providers.

* Serve as liaison with regulatory and accrediting agencies to ensure compliance with standards and act as a Dental liaison to internal/external committees and organizations

* Influence changes/enhancements to business processes, policies and infrastructure to improve operational efficiency

* Promote positive business relationships with customers

* Participate in internal and external health industry development efforts Negotiate and manage contractual arrangements

* May train, or create training, for internal dental staff or external dental vendors.

REQUIRED QUALITIFICATION:

3-5 years additional leadership and management experience in the health care industry.

Clinical knowledge/experience.

5+ years of experience in the dental care delivery system

Active unrestricted state licensure according to business requirements

This is a remote based (work from home) role and resides in New Jersey

EDUCATION:

DMD or DDS degree

ADDITIONAL INFORMATION:
Ability to assess administrative, financial and constituent impact of provider contracts.

Ability to communicate effectively with Providers, Members, and Staff & Upper Management in both an oral and written format. (e.g., may provide support to the sales staff & network staff via onsite customer visits and/or presentations).

Ability to assess administrative, financial and constituent impact of business review/credentialing operations.

Pay Range

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: 01/31/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.