Senior Utilization Management Compliance and Accreditation Specialist

Job Title:

Number of Positions:

Location:

Location Specifics:

Job Summary:

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:

Leads the Government Programs utilization management (UM) compliance functions, including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Credentialing and Recredentialing (CR) accreditations, reaccreditations, and quality improvement compliance activities. Ensures adherence to URAC/NCQA standards, state UM contractual requirements, and CMS audit standards by identifying gaps, mitigating risk, and driving corrective action plans.

Primary Job Responsibilities:

• Serves as subject matter expert on applicable URAC/NCQA, UM and CR compliance standards, elements, and factors.
• Drafts and maintains procedures, materials and reports to maintain compliance with all applicable URAC/NCQA standards and external/ internal requirements.
• Analyzes and monitors UM and CR compliance metrics; prepares routine and ad hoc reports and summarizes findings for leadership review.
• Identifies potential compliance risks or barriers to maintaining URAC/NCQA accreditation and escalates concerns as appropriate; partners with internal and external stakeholders to support mitigation strategies.
• Supports regulatory and accreditation-related audits by coordinating evidence collection, preparing documentation, tracking requests, and supporting corrective action plan development and follow-up for Government Programs State and MCO partners.
• Partners with department leadership to support compliance and quality goals, objectives, and performance measures by providing analysis, recommendations, and implementation support.
• Participates in developing and delivering internal educational programs to ensure all applicable internal stakeholders are appropriately trained on URAC/NCQA compliance requirements, best practices, time frames, and regulatory requirements.
• Maintains detailed project plans to support ongoing monitoring of URAC/NCQA standards; partners with impacted departments to document status, evidence, and remediation activities.
• Oversees the URAC/NCQA survey process for utilization management in collaboration with project lead, including data and information acquisition, accreditation application, scheduling, file review and other administrative tasks including scheduling and management of mock file reviews and surveys to periodically assess the company’s URAC/NCQA readiness on an annual basis.
• Participates in the annual process to reflect on strengths and opportunities and applies those learnings to remain URAC/NCQA compliant and/or in support of the next accreditation cycle.
• Provides compliance and accreditation subject matter support for other quality-related projects, including state utilization review/utilization management certifications or URAC-related initiatives.

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, public administration, or a related field and seven years of experience in NCQA and/or URAC quality management or compliance auditing standards. Will accept any suitable combination of education, training or experience.

Position requires general knowledge of federal and state laws, rules, and regulations; strong verbal and written communication skills; effective relationship building and interpersonal skills; strong data analytical and problem-solving skills; ability to use independent judgement to make decisions; ability to multitask and work on multiple projects at any given time; and experience with Microsoft Office applications.

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.