About the position This position is for a Dental Senior. Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations.

Responsibilities

• Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
• Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence.
• Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
• Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
• Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns.
• Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
• Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
• Trains junior-level staff to promote the development of departmental capabilities.

Requirements

• Minimum Requirements - Preferred 3-5 years of experience in a Customer Service role.
• Experience in reading or researching benefit language
• Medicare and/or Medicaid knowledge
• At least 5 years of experience that includes but is not limited to claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
• Ability to work in fast paced environment
• Excellent verbal and written communication skills.
• Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.
• Solution driven and can handle complex issues with accuracy.
• Availability to work alternating weekends for oversight of analysts on alternate schedule.

Benefits

• medical
• dental
• vision coverage
• paid time off
• retirement savings options
• wellness programs