New Job Complaints & Grievances Specialist Ii, Dentaquest (Remote) In Wisconsin

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

JOB SUMMARY:

The Complaints & Grievances Specialist II is responsible for the investigation and resolution of complaints, grievances and member appeals based upon specific regulatory requirements. In addition, responsible for the assembly and preparation of Maximus packets, State Fair Hearing packets as well as coordination and participation in State Fair Hearings. Responsible for daily interaction with assigned market/client contacts, as well as various internal departments. This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

PRIMARY JOB RESPONSIBILITIES: (NOT an exhaustive task list)

Complaint/Grievance/Appeal Resolution

• Investigate and resolve member appeals in accordance with State and/or Plan guidelines.
• Investigate and resolve complaints and grievances in accordance with State and/or Plan guidelines. Ensure all components of the grievance/complaint are researched and addressed. Complaints/grievances that this role is responsible for include:
  • Member Complaints/Grievances
  • Member Complaints/Grievances submitted by plan (when DQ is secondary)
  • Provider Complaint
  • SDOH (State Department of Health) complaints
  • DOI (Department of Insurance) complaints
  • BBB (Better Business Bureau) complaints
  • Executive complaints (complaints addressed to executives of DentaQuest)
  • Any other complaints/grievance submitted as part of the formal grievance process
• Prepare State Fair Hearing packets and coordinate and participate in State Fair Hearing reviews
• Assemble necessary information for the plan so they may appropriately investigate member appeals/complaints when we are not delegated.
• Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately. Manage workflow to meet department, Plan, State, and company goals and deadlines.
• Investigate and resolve Level II and Level III requests (TennCare market only).
• Comply with and resolve proof of compliance and directives.
• Identify when Maximus packet is necessary based on Medicare guidelines and assemble and prepare packet.
• Identify and prepare when an ODI (Ohio Department of Insurance) or IRE (independent review entity) packets are required.
• Take the lead in working with other internal departments/management team to ensure that any issues raised in the complaint/grievance that are substantiated are brought to the appropriate people’s attention.
• Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.
• Identify and resolve issues that are unusual and not consistent with standard CGA workflows.
• Attend market meetings to represent C&G and share any new issues/changes that may be impactful to others in C&G.
• Establish and maintain professional relationships with Plan contacts.

• Contact involved provider office to obtain information to properly review the case. Document provider’s/staff’s perception of the member’s concerns / issues.
• Proficiently trained to handle provider appeals and provides assistance to C&G Level 1
• Ability to identify and resolve issues that are unusual and not consistent with standard CGA workflows
• Document all complaints/grievances/appeals in department tracking system

Process Improvement

• Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
• Communicate ways to improve processes and procedures to management.

• Other duties as assigned.

JOB QUALIFICATIONS:

Required:

• High School Diploma or GED required.
• 1 year of C&G experience with demonstrated success in C&G Specialist I or 2 years’ experience in claims, customer service, provider network or another operational function.
• Proficient with general computer software including Microsoft Excel, Word and Outlook.
• Excellent verbal, written, interpersonal, organizational and communication skills.
• Excellent research skills with ability to identify underlying issue(s) not articulated
• Ability to remain calm and focused in a high pressure/high workload environment
• Ability to work in a high stress environment.
• Ability to prioritize and organize multiple tasks with tight deadlines.
• Ability to remain organized with multiple interruptions.
• Ability to work overtime as needed or required to meet business objectives.

Preferred Qualifications

• 1 year of experience in a higher-level role such as Lead or Supervisor role.
• Bachelor’s degree in Business Administration/Management or a related field, or equivalent experience in healthcare management.
• Keyboarding skills.

PHYSICAL DEMANDS:

• Incumbent must be able to communicate effectively.
• Requires overall light physical effort (up to 25lbs.)
• Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal compute).
• Ability to travel or move about within and outside serviced facilities required.
• Incumbent works primarily in either a private or shared office environment.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.

** In accordance with DentaQuest’s Compliance Plan, employee must conduct DQ business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or DQ’s Compliance Officer. **

DentaQuest’s Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program.

Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [email protected] to request an accommodation.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

Customer Service / Operations

23/11/2023

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran