Dental Claim Configuration & Processing Consultant
The Judge Group
Remote
Engagement Summary — Subject‑Matter Expert Consultant
Dental Claims Configuration & Processing
Engagement Title Subject‑Matter Expert Consultant — Dental Claims Configuration & Processing
Service Term 9‑month base term; 6‑month extension option
Engagement Type Consulting services (independent contractor; no employment relationship)
Location Remote‑first; quarterly travel to Lee’s Summit, MO
Pay Rate: Depends on experience
Background & Context
Our client is the second‑largest carrier in the Federal Employees Health Benefits (FEHB) program, serving approximately 2.1 million federal members. Following the 2025 transition of medical, dental, and member services to UMR (an Optum subsidiary), our client is expanding its internal oversight capabilities to address documented dental quality issues, including configuration errors, faxback misrepresentations, and provider dissatisfaction.
2. Scope of Services
2.1 Configuration Assessment & Root‑Cause Analysis
Conduct comprehensive assessment of dental claims platform configuration across FEHB and PSHB lines of business.
Identify configuration risks prior to defect manifestation; document defect categories with frequency, member impact, and recommended remediation paths.
Provide root‑cause analysis on dental claims defects, including incorrect benefit application, accumulator errors, EOB clarity issues, and provider faxback misrepresentations.
2.2 Dental Quality Assessment
Evaluate current dental faxback quality and recommend improved content standards.
Review provider communication standards for dental claims processing (clarity, timeliness, dispute resolution).
Develop recommended pattern‑detection routines to surface dental claims anomalies before member or provider complaints occur.
2.3 Advisory Support
Provide written and verbal advisory input to the Interim COO on dental operations, vendor configuration changes, and remediation priorities.
Support the Interim COO in dental‑specific vendor governance preparation; consultant will not directly engage the vendor during the first 30 days.
4. Required Consultant Qualifications
20+ years of dental claims operations leadership at scale, including accountability for dental claims accuracy at large dental plans ($500M+ annual paid claims).
Hands‑on experience with dental claims platform configuration and benefit setup.
Documented track record in dental faxback quality, EOB clarity, and provider communication standards.
Experience operating under regulatory scrutiny (state insurance departments, OPM, CMS, or comparable).
Demonstrated ability to perform root‑cause analysis that withstands external audit review.
Availability to begin engagement within 4–6 weeks of contract execution.
5. Preferred Consultant Qualifications
Federal program dental experience (FEHB Dental, Tricare Dental, Medicare Advantage dental, or comparable).
Direct experience with UMR Dental, UnitedHealth Dental, or comparable national TPAs.
Expertise with dental platforms such as Plexis, Facets dental module, HealthRules, QNXT, or major proprietary TPA platforms.