Complaints, Grievances & Appeals Specialist II
Location: Milwaukee, Wisconsin, United States
Remote Opportunity: 1
Requisition Number: 3241
Position Title: Complaints & Grievances Specialist II
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)
• 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:
o Member Complaints/Grievances
o Member Complaints/Grievances submitted by plan (when DQ is secondary)
o Provider Complaint
o SDOH (State Department of Health) complaints
o DOI (Department of Insurance) complaints
o BBB (Better Business Bureau) complaints
o Executive complaints (complaints addressed to executives of DentaQuest)
o 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
• 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.
• 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.
• 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.
• 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.
Community / Marketing Title: Complaints, Grievances & Appeals Specialist II
At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.
Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.
To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.
The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.
Location_formattedLocationLong: Milwaukee, Wisconsin US
CountryEEOText_Description: Equal Employment Opportunity Statement: DentaQuest is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religious creed, national origin, sex, age, disability, marital status, or sexual orientation.