Dental Director’s Office. Contractor will employ and designate a full-time Dental Director responsible for the development, implementation, and review of the internal quality assurance program (QAP). The Dental Director will have adequate and appropriate experience in successful QA programs and be given sufficient time and support staff to carry out the Dental Plan's QA functions. Contractor may use assistant or associate Dental Director to help carry out the responsibilities of this office. The Dental Director’s qualifications and responsibilities shall at a minimum include, but are not limited to the following: • Possess an unencumbered licensed to practice dentistry in the State of Rhode Island and be board-certified, board eligible, or board trained in his or her field of specialty. • Be responsible for Contractor’s UR and QA Committees, direct the development and implementation of Contractor’s internal Quality Assurance Plan, utilization review activities, and monitor the quality of care that members receive • Be responsible for the development of dental practice standards and protocols for Contractor • Oversee the investigation of all potential quality of care problems, including but not limited to member-specific occurrences of possible Health Care- Acquired Conditions and Other Provider-Preventable Conditions in accordance with 42 CFR 447.26, 434.6(a)(12), 438.3(g), and Section 2703 of the Patient Protection and Affordable Care Act , and possible hospital acquired conditions and recommend development and implementation of corrective action plans • Be responsible for the development of Contractor’s dental policies • Be responsible for the Contractor’s referral process for specialty and out- of-plan services • Be involved in the Contractor’s recruiting and credentialing activities • Be involved in the Contractor’s process for prior authorizing and denying services • Be involved in the development and oversight of the Contractor’s disease management programs • Be involved in the Contractor’s process for ensuring the confidentiality of dental records/client information • Serve as liaison between the Contractor and its providers and communicate regularly with the Contractor’s providers, addressing areas of clinical relevance including but not limited to: ⮚ Contractor’s utilization management functions ⮚ Any prior authorization (PA) requirements ⮚ Quality indicators, such as the Contractor’s performance on HEDIS-like measures • Participate in the development of strategies to educ...
