Job Title:

Adult DBM-MCO Coordinator

Number of Positions:

0

Location:

Nashville, TN

Location Specifics:

Hybrid Position

Job Summary:

Must reside in Metropolitan Davidson County, Tennessee or a county contiguous to Metropolitan Davidson County, Tennessee.

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description

Oversees delivery of dental care and benefits management for adults and coordinates with managed care organizations (MCO) to ensure the effective delivery of dental services.

Primary Job Responsibilities

• Coordinates with MCOs to ensure alignment on adult dental benefit offerings, network adequacy, and quality standards, including exchanging data such as member eligibility, referrals, treatment plans, stratification of proposed treatment plans, procedures, authorizations, and other information, as necessary.
• Develops and maintains a system for data exchange with the MCOs and the Contractor that includes referrals, treatment plans, stratification of proposed treatment plan procedures, authorizations, and other necessary information.
• Coordinates care with DBM case managers and MCOs for all services, with specific focus on anesthesia, complex oral surgery or trauma cases, cases treated in an ASC or hospital setting, or any other medical-dental integrated case.
• Ensures effective dental care within the adult dental benefit parameters, including provider reimbursement limitations, claims processing adjudication and payment for cases coordinated with the applicable MCO, and management of third-party liability, both dental and medical.
• Conducts regular reviews and audits to ensure MCO and DBM compliance with Medicaid regulations and internal policies for adult population.
• Supports the identification and implementation of quality improvement initiatives to enhance patient outcomes and provider performance.
• Supports other quality initiatives for Medicaid population, including care coordination and case management, member outreach, attendance at community events, performance improvement projects, and value-based payment projects.
• Develops applicable reporting for MCO-DBM coordinated cases, including state required reports, internal reporting, and MCO delegated reports.
• Coordinates with MCOs to identify medical facilities willing to partner on reserved operating room access time for dental services, as well as collaborates with the Child Dental DBM-MCO Coordinators and I/DD DBM-MCO Coordinator to ensure members' needs are met and facilitate group planning.
• Maintains detailed records of each member case treated in the hospital or surgery center to ensure the reserved times are used for dental cases and services are delivered as expected.
• Facilitates communication and collaboration between MCOs and dental providers to enhance service delivery.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a bachelor’s degree in business administration, healthcare administration, public health, dental hygiene or a related field and three years of experience utilizing analytical tools and software, dental claims billing or review, or dental software. Previous experience working with health plans, insurance, or in healthcare settings is preferred. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of dental terminology and dental procedures; experience working with word processing, and spreadsheet software; strong verbal and written communication skills; strong organizational and analytical skills; ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment.

Position requires travel of 10-25% throughout the state of Tennessee, and nationally as necessary.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.