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The Manager of Clinical Quality and G&A Review is responsible for overseeing the day-to-day operations of the clinical appeal review process, and performing activities that evaluate and improve the quality and safety of care and services. This individual will also assist in the design and implementation of quality improvement initiatives in support of the strategic objectives of the organization.
Responsibilities- Responsible for the operational execution of clinical quality management (QM) activities and appeal day-to-day operations; guides Clinical QM/G&A units to meet and exceed department quality, compliance, timeliness and production goals.
- Provides overall clinical leadership and governance for the Grievance & Appeals (G&A) Department, ensuring all clinical reviews are conducted in accordance with regulatory standards and organizational policies ensuring consistent application of plan policies and contractual requirements.
- Oversee monitoring and reporting as required by regulation or contract; Identifies provider trends discovered through PQI, PQR and G&A case review.
- Analyzes clinical trends and outcomes to identify emerging risks, assesses potential quality concerns, and uncover opportunities for process improvement, while driving strategic initiatives across internal teams and cross-functional partners.
- Identifies potential quality risks or opportunities for process improvement and implements appropriate courses of action.
- Serves as clinical subject matter expert, providing guidance to internal stakeholders and collaborating cross-functionally to deliver processes procedures, and systemic training opportunities and efficiencies to support QM and appeal team members.
- Develops P&Ps, workflows and required documents to meet federal and state regulatory requirements.
- Oversees health promotion and quality initiatives.
- Acts as educator and resource to departments in matters of health care quality.
- This list is not all-inclusive and you are expected to perform other duties as requested or assigned.
- 8+ years w/Bachelor’s degree; 1+ years supervisory/management
- 2-3 years' experience Quality Management Review, Denial Management, Case Management, or related experience, including leadership in a clinical operational area
- Minimum 5 years' experience in health insurance
- Excellent organizational and time management skills, with the ability to meet strict internal and regulatory deadlines with highly confidential information.
- Ability to establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.
- Excellent written, verbal, and electronic communication skills.
- Strong critical thinking, problem-solving, and decision‐making/resolution skills.
- Excellent team building, training, and leadership skills.
- Intermediate knowledge of Microsoft Office programs including Word, Excel, and Outlook.
Licenses
• Unrestricted California Dental License Required
• Certified Project Management Professional (PMP)-PMI. Preferred
• Six Sigma Green Belt Certification. Preferred
Base Pay Information
The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.
Pay Grade 22. $93,445.00 - $202,465.00.
- Competitive base and incentive pay
- 401(k) with robust matching and non-matching contributions
- Rich medical & pharmacy benefits
- 100% employer-paid dental and vision benefits
- Holistic wellbeing program with deep financial incentives
- Generous paid time off plus 12 paid holidays and your birthday off
- Culture of growth and learning: career development; tuition reimbursement; recognition program
- Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
- Social responsibility and volunteer opportunities
- Employee discount program
Skills Required
- Bachelor's degree with 8+ years of experience
- 1+ years supervisory/management experience
- 2-3 years experience in Quality Management Review, Denial Management, Case Management, or related clinical operational leadership
- Minimum 5 years' experience in health insurance
- Unrestricted California Dental License
- Background check required
- Excellent organizational and time management skills with ability to meet regulatory deadlines and handle confidential information
- Ability to establish and maintain effective interpersonal relationships across staff and external agencies
- Excellent written, verbal, and electronic communication skills
- Strong critical thinking, problem-solving, and decision-making/resolution skills
- Team building, training, and leadership skills
- Intermediate knowledge of Microsoft Word, Excel, and Outlook
- Project Management Professional (PMP) certification
- Six Sigma Green Belt certification
Delta Dental Insurance Company Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Delta Dental Insurance Company and has not been reviewed or approved by Delta Dental Insurance Company.
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Retirement Support — Retirement support is positioned as a standout element, including a sizable automatic 401(k) contribution plus additional matching. This boosts overall total-rewards value even when base pay is viewed as only mid-market in some areas.
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Affordable Benefits — Core coverage is framed as unusually low-cost to employees, including fully employer-paid dental and vision and low employee contribution medical options. This creates meaningful take-home value beyond cash compensation.
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Leave & Time Off Breadth — Time-off offerings are described as generous, including broad PTO/holidays and additional paid leave features such as parental leave. These policies increase perceived rewards and help balance workload demands.
Delta Dental Insurance Company Insights
What We Do
At Delta Dental, we’re behind millions of smiles and counting. For over 68 years, we’ve served our communities by increasing access to affordable, quality care – but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building programs that offer opportunities for advancement, create meaningful connections, and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all. We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania, and Delta Dental Insurance Company are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country. Together with our affiliate companies, form one of the nation’s largest dental benefits delivery systems, covering over 31 million enrollees. Headquartered in San Francisco, we are members of the Delta Dental Plans Association, a network of companies that provides dental coverage to 80 million people. Delta Dental provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
