Dental Policy & Quality Manager

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.

G.E.H.A has one mission: To empower federal workers to be healthy and well.

The Dental Policy & Quality Manager owns the clinical policy, coding, education, and data quality functions that ensure G.E.H.A’s dental benefit programs operate with accuracy, consistency, and clinical integrity. This role sits within the product team and serves as the organization's recognized clinical authority on dental benefit policy, CDT coding standards, and coverage criteria — providing the clinically defensible policy foundation that the program depends on to make sound, defensible decisions.

This is a senior-level individual contributor role carrying functional authority over the clinical policy and quality discipline, requiring deep dental clinical and benefit expertise combined with the ability to translate that expertise into practical program infrastructure — documented policies, provider and member education, coding alignment with vendors, and accurate data reporting to the Office of Personnel Management (OPM).

Initially, the role carries significant foundational work: auditing and realigning existing coverage policies against G.E.H.A's actual program needs, current CDT standards, and vendor adjudication practices. Over time it transitions into ongoing ownership, maintenance, and continuous improvement of those systems.

Coverage determinations, clinical review criteria, and coding standards approved through this role establish the governing policy direction for G.E.H.A’s third-party administrator and clinical review vendor and are used to support OPM audits and regulatory reviews.

SKILLS

Duties & Responsibilities

Dental Coverage Policy Development & Governance

Own development, documentation, and ongoing maintenance of G.E.H.A's dental coverage policies, including benefit criteria, code-level guidance, annual CDT updates, and a version-controlled policy library that serves as the program's source of truth.

Lead the initial policy audit and realignment effort by identifying outdated language, coverage gaps, coding inconsistencies, and misalignment with CDT standards, vendor adjudication practices, clinical review criteria, and G.E.H.A plan provisions.

Serve as G.E.H.A's final dental policy and coding authority for TPA and clinical review vendor alignment, OPM filings, benefit reviews, member escalations, audit findings, and interpretation of coverage requirements.

Coordinate the annual BENEFEDS CDT reporting process with TPA and Data & Analytics, ensuring accurate validation and timely submission of CDT cost and utilization data.

Chair the clinical policy review process, convening actuarial, compliance, legal, network, and operations stakeholders to evaluate proposed policy positions and issue approved determinations of record.

Establish the clinical evidence standards and documentation protocols by which coverage positions are developed, ensuring each determination is defensible under federal audit.

Member, Provider & Network Support

Provide dental clinical content and review member and provider education materials from a dental clinical perspective, including benefit explainers, coverage guidance, CDT coding content, policy summaries, provider updates, webinars, and website or self-service content.

Translate complex coverage policy, clinical criteria, and coding requirements into clear, audience-appropriate language for members, providers, internal partners, and escalation teams.

Provide dental policy and coding SME support to Network Oversight for provider questions, coding disputes, coverage inquiries, adequacy reviews, DSO/provider communications, and provider trust or advocacy initiatives.

Serve as G.E.H.A's clinical representative in escalated provider disputes where coverage or coding positions are formally challenged.

Clinical Review Vendor Contract & Performance Oversight

Own the clinical review vendor contract and day-to-day relationship, including renewal timelines, invoicing, SLA compliance, performance documentation, and audit-ready contract records, and partner with Procurement on renewal negotiations and contract terms.

Monitor vendor performance, determination consistency, clinical accuracy, turnaround compliance, and documentation quality; escalate gaps with clear findings, root cause themes, and corrective action recommendations.

Direct the clinical review vendor relationship, including workflow governance, case routing, quality reviews, policy alignment corrections, implementation of updated review criteria, and escalation of sustained performance gaps through corrective action plans or recommended contractual remedies.

Regulatory Defense & Audit Accountability

Serve as G.E.H.A's clinical policy representative in OPM audits, site visits, and regulatory inquiries, defending coverage positions and clinical criteria directly to federal reviewers.

Advise leadership on regulatory and financial exposure created by policy gaps, coding misalignment, or vendor determination inconsistency, and recommend mitigation in advance of federal review.

Lead root-cause analysis and remediation for policy-driven claims payment errors, coordinating corrective action across the TPA, configuration, and operations teams.

Ensure clinical policy documentation meets evidentiary standards sufficient to withstand OPM audit, appeal review, and external challenge.

Technical Direction & Professional Development

Provide technical direction and clinical guidance to external clinical reviewers, ensuring determinations align with approved G.E.H.A criteria.

Coach and develop internal staff on dental benefit interpretation, CDT coding application, and clinical policy reasoning, elevating organizational capability.

Serve as the escalation point for complex clinical coverage questions, coding disputes, and methodology disagreements across the organization.

Establish the quality standards and review protocols applied to dental clinical policy and coding work performed by others.

Knowledge, Skills, and Abilities

Bachelor's degree in Dental Hygiene, Health Administration, Health Informatics, or a related field required, advanced degree preferred.

Dental clinical training, licensure, or certification (RDH, DDS, or equivalent) required, or demonstrably equivalent clinical depth gained through sustained dental utilization management or clinical policy practice; deep working knowledge of dental procedures, CDT coding, and clinical benefit criteria required.

Additional years of qualifying relevant work experience may be considered in lieu of formal education.

Requires a minimum of 10 years of progressive experience in dental benefits, dental policy development, dental utilization management, or managed dental care — with demonstrated ownership of coverage policy or coding functions, not just execution of assigned tasks, including at least 3 years in a lead or functional authority capacity.

Deep subject matter expertise in dental benefit policy, CDT codes, ADA coding guidelines, and dental benefit structures required; recognized across the organization and by external partners as the authoritative voice on coverage criteria and coding standards, with experience monitoring, assessing, and implementing annual CDT code updates in a health plan environment required.

Direct experience developing or maintaining dental coverage policies in a health plan, TPA, or managed care environment required.

Experience partnering with TPAs or clinical revi