Western Dental & Orthodontics
Payor Relations Manager
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Job Description
- Req#: 21084
- Maintain payor Provider Guides, ensuring accurate fee schedules, and terms across all locations.
- Engage with payor account managers, initiating regular check-ins to review network performance and resolve outstanding issues.
- Lead the resolution of escalated payor complaints, including those related to patient grievances, service coverage disputes, and claim denials.
- Coordinate with clinical and billing teams to gather supporting documentation and formulate compliant, timely responses.
- Maintain a centralized complaint tracking system to monitor trends, root causes, and resolution outcomes.
- Ensure responses to formal complaints and regulatory inquiries are thorough, timely, and aligned with contractual and legal standards.
- Coordinate internal responses to payor-initiated audits, quality assurance reviews, and documentation requests.
- Work closely with compliance and clinical leadership to ensure accurate, complete, and audit-ready patient records.
- Monitor payor quality metrics and ensure clinical documentation and billing practices align with payor QM requirements.
- Serve as the liaison for QM corrective action plans when required by payors, ensuring timely follow-through and implementation.
- Track payor performance metrics including denial rates, complaint trends, and appeal outcomes.
- Develop and present actionable reports to senior leadership to inform strategic decision-making.
- Training & Communication:
- Educate internal teams on payor policy changes, documentation requirements, and best practices for complaint and audit readiness.
- Partner with compliance and operations to continuously refine internal workflows based on audit outcomes and complaint trends.
- 3–5 years of experience in dental or healthcare payor relations, contract negotiation, and/or claims resolution within a DSO or insurance environment.
- Strong working knowledge of CDT codes, dental billing, and documentation standards.
- Experience handling formal payor complaints, appeals, and QM audits.
- Exceptional communication, documentation, and negotiation skills.
- Analytical mindset with attention to compliance and audit detail.
- Ability to manage sensitive complaint and audit data with discretion.
- Proficiency in dental software systems and Microsoft Office, particularly Excel and SharePoint.
Overview
As a Payor Relations Manager within our Dental Service Organization (DSO), you will act a key liaison between our multi-site dental practices and third-party payors. This role is responsible for maintaining strong payor relationships, resolving mid-level insurance issues, and supporting compliance through complaint management and quality audit preparation.
Responsibilities
Payor Guidelines & Relations:
Complaint Resolution:
Quality Management (QM) & Audit Support:
Data Analysis & Tracking:
Qualifications
Skills
Work Environment
On Site; occasional travel to practice sites or payor meetings.
About the company
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