Operations Documentation Specialist II (Remote)

Location: Milwaukee, Wisconsin, United States

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Remote Opportunity: 0

Requisition Number: 3790

Position Title: Operations Documentation Specialist II

External Description:

JOB SUMMARY: PRIMARY JOB RESPONSIBILITIES:

  • Identify changes to State and/or Federal regulations, MCO contracts or NCQA requirements that may affect content of letters generated from Utilization Management and Complaints and Grievances activity.
  • Participate in Market Meetings to understand Client requirements and communicate any items that impacts determination or appeal letters. Perform quality audits daily on determination letters.
  • Communicate any potential errors identified in auditing determination letters to the identified contact person(s) for the area that generates the document.
  • Identify non-compliant determination letters and communicate to Operations Management.
  • Work with UM to have denials overturned if required by State/Plan if letters are non-compliant.
  • Coordinate with UM and C&G to submit determination letters for audits in the required timeframe
  • Coordinate with Correspondence System team to correct any process issues that may cause errors with determination letters identified during the daily audit.
  • Maintain documentation and track/trend errors identified during daily audit process.
  • Batch and print member determination letters and prepare for mailing.
  • Identify additional process improvements for determination letter process.
  • Assist Supervisor with requests from health plans for determination letter information.
  • Provide assistance to other departments with determination letter requests.
  • Research and coordinate file requests for client audits.
  • Perform duties of Operations Document Specialist I, as necessary.
  • Perform clinical peer reviews.
  • Other duties as assigned.

JOB REQUIREMENTS:

  • High School Diploma or equivalent. 2 years’ experience in clerical setting.
  • Ability to prioritize and organize multiple tasks.
  • Ability to work independently.
  • Good PC Skills. Good Analytical ability.
  • Strong attention to detail.
  • Typing skills of 30+ wpm.
  • Excellent verbal and written communication skills.
  • Ability to remain organized with multiple interruptions.
  • Good knowledge of Word and Adobe PDF Writer programs.
  • Knowledge of general computer software.
  • Knowledge of telephone systems.
  • Reports to and works under the supervision of the Correspondence Supervisor.
  • Interacts in a cooperative, professional and effective manner with Provider offices, Health Plans, and members.
  • Interacts in a cooperative, professional and effective manner with co-workers and company staff.
  • Interacts in a cooperative, professional and effective manner with visitors.
  • Required to attend additional training as requested/deemed necessary.

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 computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.

City: Milwaukee

State: Wisconsin

Community / Marketing Title: Operations Documentation Specialist II (Remote)

Company Profile:

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.

Company Profile Job:

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: In accordance with our Compliance Plan, employees must conduct business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or Compliance Officer. 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 see Human Resources for additional information regarding this Program. Equal Employment Opportunity Statement: We are committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or sexual orientation.

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