Job Summary
The Grievance & Appeals Specialist is responsible for the review, investigation and resolution of all appeals and grievances from providers, non-contracted providers and plan members to ensure the highest level of service to these individuals and groups. All actions are to be completed in a timely manner in accordance with established Company and regulatory standards.
Essential Responsibilities
- Investigates and responds to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and Company processing timelines and guidelines.
- Conducts thorough investigations of all related participant/member, and provider correspondence through a comprehensive fact finding review to understand all the issues involved.
- Obtains required information from various Company departments and personnel, and external entities, contracted vendors, and state and federal regulatory agencies, delegated entities, Medical Groups and Network Physicians.
- Ensures timely resolution of cases even when additional discussions are required to assess submitted appeals and grievances and accurately documents all actions and resolutions.
- Recommends final resolution of complaints, grievances and appeals to management, which may include recommending corrective action to be taken regarding employees, processes, or policies.
- Prepares detailed written resolution responses to all members, participants and providers.
- Provides all administrative related information and routes accordingly for proper clinical review.
- Prepares all initial and final adverse determination letters.
- Identifies potential quality of care issues and directs cases to the appropriate person/department for review as needed.
- Prepares and provides all necessary and requested reports and prepares reports for presentation at various committees and departments.
- Demonstrated ability to manage multiple projects and be flexible.
- Effectively resolving appeals and grievance submissions from providers, members and others to the satisfaction of all parties
- Demonstrated ability to manage multiple projects and be flexible.
- Effectively working with team members across the enterprise to resolve submitted issues and accurately document all actions and resolutions
- Maintaining a high level of integrity and appropriate confidentiality in all activities and efforts.
- Addresses and resolves a wide variety of basic to complex member, provider and other issues and problems.
- Supports improvements in processes, programs, productivity and services.
- Performs any and all additional duties as requested and directed for this position.
Basic Qualifications
Experience
- Minimum of 2 years of related experience
Education
- High school diploma or equivalent
- Some college preferred
License, Certification, Registration
Additional Requirements
- Knowledge of appeals and grievance processes, procedures and operations in a dental plan member/provider environment.
- Knowledge of problem resolution principles, HIPAA/ PHI safeguards and other applicable regulations and requirements in a healthcare setting.
- Strong written and verbal communication skills and problem-solving techniques.
Preferred Qualifications
- Knowledge of dental terminology and procedures
- Bilingual English/Spanish
Position Details
- Primary Location: Long Beach, California
- Job Schedule: Full time
- Scheduled Weekly Hours: 40
- Shift: Monday – Friday; 8:00 am to 5:00 pm
- Travel: No
We look forward to having you on our team!