Remote Utilization Management Nurse Jobs in Reno, NV

JOB DESCRIPTION 

Provides support and subject matter expertise for member clinical dental review activities. Responsible for determining appropriateness and medical necessity of member dental care services - targeting opportunities for quality improvement and satisfaction for members and providers. Participates with senior leadership to establish strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care.
 

Essential Job Duties

• Oversees all aspects of utilization review and quality management activities related to dental care services for members, including appropriateness and medical necessity of dental care services provided.
• Provides oversight for dental quality programs including Healthcare Effectiveness Data and Information Set (HEDIS) and Pay For Performance (P4P).
• Develops and implements clinical utilization processes and algorithms utilized in the authorization process including: statistical methodology for use in utilization management, provider profiling analytics, dental policies and procedures and quality improvement activities.
• Partners with provider contracts to secure and maintain a network of dental providers.
• Meets or exceeds established review productivity standards.
• Educates and interacts with network and group providers regarding utilization practices, guideline usage, and effective member management; provides clinical representation for business presentations in partnership with provider relations.
• Provides guidance to staff regarding appeals, grievances and member/provider complaints.
• Provides analytics and interpretation of dental benefit plan structures.
• Maintains accountability for consumer/member related decisions for self and network of dental consultants.
• Ensures that the dental care provided meets the standards for acceptable dental care and that dental protocols and rules of conduct for plan personnel are followed.
• Participates in professional and community activities to provide input/demonstrate dental knowledge related to regulatory, professional and community standards, and issues. 
 

Required Qualifications

• At least 7 years of dental practice experience, including 3 years of experience working in a managed care, insurance, or benefits administration setting, or equivalent combination of relevant education and experience.
• Doctor of Medicine in Dentistry (DMD) or Doctor of Dental Surgery (DDS). License must be active and unrestricted in state of practice.
• Health care management/leadership experience preferred.
• Current clinical knowledge.
• Ability to gather information and coordinate workflows.
• Ability to work independently and within a team environment.
• Effective time-management and organizational skills.
• Critical thinking and listening skills.
• Decision-making and problem-solving skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
 

Preferred Qualifications

• Peer review, medical policy/procedure development and provider contracting experience.   
• Knowledge of National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), Medicare, Group/Independent Physician Association (IPA), capitation, health management organization (HMO) regulations, managed health care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management and evidence-based guidelines.

• Active dental licensure in Southwest region (AZ, CA, NV, NM, TX).
• Active membership in a recognized professional organization, such as the American Dental Association (ADA) or National Dental Association (NDA).
   

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $129,504 - $215,040 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.