Complaints & Grievances Specialist II – Dentaquest

Complaints & Grievances Specialist II – Dentaquest

Requirements

• 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.

Responsibilities

• 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.
• Prepare State Fair Hearing packets and coordinate scheduling 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.
• Comply with and resolve proof of compliance and directives.
• Contact involved provider office to obtain information to properly review the case. Document provider’s/staff’s perception of the member’s concerns / issues.
• Document all complaints/grievances/appeals in department tracking system.

Preferred Qualifications

No preferred qualifications provided.