Director, Utilization Management - DentaQuest

Director, Utilization Management - DentaQuest

Location: We support US flexible working arrangements in the contiguous 48 states.

Job Description:

The Director, Utilization Management participates in the design, strategic planning, development, implementation, and administration of all aspects of the utilization management programs. The scope of utilization management is inclusive of technologies that improve efficiency, quality, and accuracy. The position maintains delivery of a high value (both clinical and financial) utilization management program and for assuring members receive high quality and appropriate clinical care in a timely and cost-effective manner. The Director will also be responsible for developing strong cost and quality oversight procedures with vendor or sub-delegate partners.

How you will contribute:

• Ensures that the right systems, processes, and measurements are in place to demonstrate the value and clinical effectiveness of utilization management programs to customers.
• Enhances operational efficiency to optimize and maximize staff and external partner productivity and value.
• Contribute to business unit objectives through the recommendation, development, and implementation of utilization management models.
• Work with other internal departments as necessary to implement strategies and programs to proactively manage dental utilization costs within each market to assure profitability and budgetary goals are met.
• Develops and implements process and program redesigns.
• Handle detailed utilization evaluation and benchmarking.
• Manage department budget.
• Oversee projects that improve efficiency and ensure resultant budgetary and performance goals are measured and achieved.
• Maintain relationships with client contacts and attend in-person client or sales meetings as needed.
• Represents the company to a variety of external stakeholders including provider organizations, customers, advocacy groups, and government entities as needed.
• Manages relationships and operations with external partners/vendors that provide services as part of the UM program.
• Oversee and direct utilization management department personnel and metrics to ensure compliance with business unit objectives.
• Meets applicable regulatory and compliance standards and accreditation requirements by maintaining a continuous quality improvement program to aid external and internal audits.
• Develop team by managing the overall activities of the department including employee coaching, development, and review.
• Develop and manage staffing models and operational processes to ensure analysis, data, reports, initiatives, and projects are completed accurately and efficiently to meet organizational and client needs.
• Responsible for assuring the documentation, monitoring, and development of training material and training of departmental staff in utilization management guidelines and processes.
• Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Provide recommendations on department policies, objectives, and initiatives. Evaluate and suggest changes as necessary to optimize processes and efficiencies. Works in partnership with technical team and/or vendors to improve system efficiency and remains current on industry trends and technologies.
• Establishes department goals and performance metrics that assist the department and enterprise strategic plans.
• Establishes rigorous performance measurement and improvement to ensure that business processes are efficient, staff is optimally deployed, and programs achieve their intended outcomes and customer commitments.
• Owns coordinating and implementing appropriate performance management strategies for team members, including hiring, training, and performance evaluation. Establish standards for Department.
• Assist with answers and evaluation for Request for Proposals (RFP) as needed.
• Other duties as assigned.

What you will bring with you:

• Management/supervisory experience, 10 or more years.
• 5 years clinical experience in the dental industry is a plus.
• Requires research and analytic skills or an ability to oversee, understand, and articulate the results of the research and analysis to perform many of the responsibilities outlined above.
• Knowledge and understanding of regulatory language.
• Excellent oral and written communications skills.
• Experience managing cross-functional projects.
• Knowledge of managed care health plans operations and HIPAA guidelines.
• Experience and knowledge in intermediate computer skills.

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Life is brighter when you work at Sun Life

• Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical, and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more.
• Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account.
• A flexible work environment with a friendly, caring, collaborative, and inclusive culture.
• Great Place to Work Certified in Canada and the U.S.
• Named as a “Top 10” employer by the Boston Globe's “Top Places to Work” two years running.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

If you are a California resident, the salary range for this position is:

• Southern California region: $142,200 - $213,300 annually.
• Central California region: $149,800 - $224,700 annually.
• Northern California region: $160,200 - $240,300 annually.

If you are a Colorado or Nevada resident, the salary range for this position is $135,700 - $203,600 annually. If you are a Connecticut or Maryland resident, the salary range for this position is $142,200 - $213,300 annually. If you are Washington or Rhode Island resident, the salary range for this position is $149,800 - $224,700 annually. If you are a New York resident, the salary range for this position is $160,200 - $240,300 annually.

We consider various factors in determining actual pay including your skills, qualifications, and experience. In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

Job Category: Claims - Health & Dental

Posting End Date: 23/10/2024