Director, Professional Review and Utilization Management

Director, Professional Review & Utilization Management

Bring your clinical expertise and leadership skills to Delta Dental of Illinois. As Director, Professional Review & Utilization Management, you’ll lead dental consultants, oversee clinical reviews and appeals, and strengthen policies that support consistent, appropriate benefit decisions.

What You’ll Do

• Lead clinical claims reviews, including second-level determinations, in accordance with Delta Dental guidelines.
• Train, coach, and manage dental consultants; promote consistent clinical determinations through standardization exercises.
• Oversee clinical appeals and second-level dentist reviews; conduct peer-to-peer discussions with treating dentists.
• Resolve quality-of-care and treatment grievances; investigate fraud, waste, and abuse and recommend resolutions to the Vice President, Dental Science & Network Strategy.
• Assess treatment necessity and appropriateness; answer policy inquiries and guide Professional Relations, Claims, and Customer Service on escalated clinical matters.
• Manage professional review vendors and monitor performance, quality, and clinical consistency.
• Partner with the Vice President, Dental Science & Network Strategy on review policies and utilization guidelines; support dental policy, quality management, utilization data, and peer review.
• Analyze utilization trends and outlier provider patterns, oversee site reviews and quality audits, and track review timeliness, accuracy, and consistency.
• Lead planning, budgeting, team development, and performance management; serve on assigned projects and fraud, quality, and peer review committees.