Clinical Dental Quality Consultant – Aetna Dental (Remote)

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important... as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. As a CVS Health® company, Aetna Dental® has 60+ years of experience providing excellent dental care to more than nine million members. The Clinical Dental Quality Consultant will assure that members receive quality dental care. This individual contributor role will be a key partner to the Compliance and Medicare business segments. The Clinical Dental Quality Consultant reports to Aetna’s National Dental Director and serves as a liaison and is accountable to the governing body and Quality Management Committee for all QM activities and initiatives. The Clinical Dental Quality Consultant is familiar with local standards of dental practice and nationally accepted standards of care. This position is fully remote. Qualified candidates can live anywhere in the US. Primary Job Duties and Responsibilities

• Provide professional input, analysis, opinions and clinical expertise for Aetna DMO, PPO, and Medicare operational functions, following strategic goals established by the Plan
• Participate in and sit on committees for the various filed entities of the organization as directed by Aetna leadership
• Assure compliance with laws and regulations in all states
• Support the execution of partnerships that provide Aetna Dental with cross-continuum capabilities (e.g. social determinants of health, etc.)

Responsibilities (time percentages)

• Provide clinical review of complaints and grievances, and assist in the development of resolutions to meet regulatory statutes (65 % of time)
• Follow and participate in Aetna Quality Management processes, including credentialing, site assessments, peer review, complaints, grievances and appeals (25% of time)
• Support Dental Claims staff ensuring timely and consistent responses to members and providers (5% of time)
• Provide clinical expertise in support of identifying and investigating potential dental fraud, waste, and abuse (5% of time)

Minimum Requirements

• Valid state license to practice dental hygiene
• Minimum 10 years of dental hygiene clinical practice
• Demonstrated success with project management, leadership, analysis, and implementation
• Knowledge of dental conditions and treatment, dental coding, billing, and current trends in the dental profession
• Basic understanding of dental benefit products and platforms (DMO, PPO, Medicare Advantage)
• Proficient in Microsoft Office applications

Preferred Requirements

• Understanding of value-based contracting options, clinical quality programs, and clinical integration
• Financial acumen, coupled with strong problem solving and analytical abilities
• Excellent written, verbal, and presentation communication skills
• Familiar with state regulatory bodies such as the CA Department of Managed Health Care
• Capable of building relationships with a variety of professional personalities including community dentists, dental hygienists, physicians, DSO leadership, and Aetna executive leaders

Education Dental Hygiene Degree Pay Range The typical pay range for this role is: $105,446.25 - $227,100.00 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. 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 jobs.CVSHealth.com/benefits We anticipate the application window for this opening will close on: 08/26/2024 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws Apply to This Job Check More Jobs Apply To this Job Apply for this job