Complaints & Grievances Specialist II, DentaQuest

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

Job Description:

Location: We support US flexible working arrangements in the contiguous 48 states.

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America. 

The opportunity:  
The Complaints & Grievances Specialist II handles 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.  Accountable for daily interaction with assigned market/client contacts, as well as various internal departments.  This position is also ensures that all mandated turnaround times are met as well as required processes and workflows are adhered to.

How you will contribute: 

• 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:
  • Member Complaints/Grievances
  • Member Complaints/Grievances submitted by plan (when DQ is secondary)
  • Provider Complaint
  • SDOH (State Department of Health) complaints
  • DOI (Department of Insurance) complaints
  • BBB (Better Business Bureau) complaints
  • Executive complaints (complaints addressed to executives of DentaQuest)
  • Any other complaints/grievance submitted as part of the formal grievance process

• 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

What you will bring with you:

• 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.

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you. 
  

Not ready to apply yet but want to stay in touch?  Join our talent community (https://pages.beamery.com/sunlifecareers/page/join-us-canada) to stay connected until the time is right for you! 

Life is brighter when you work at Sun Life 

• Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more 
• Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account  
• A flexible work environment with a friendly, caring, collaborative and inclusive culture  
• Great Place to Work® Certified in Canada and the U.S.  
• Named as a “Top 10” employer by the Boston Globe's “Top Places to Work” two years running 

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. 
 

If you are a California resident, the salary range for this position is: 

• Southern region: $54,700 - 77,620 annually  
• Northern region: $58,500 - 83,100 annually  

If you are a Colorado or Nevada resident, the salary range for this position is $49,500 - 70,260 annually.
If you are a Connecticut or Maryland resident, the salary range for this position is $51,800 - 73,520 annually 
If you are Washington or Rhode Island resident, the salary range for this position is $54,700 - 77,620 annually  
If you are a New York resident, the salary range for this position is $58,500 - 83,100 annually  

We consider various factors in determining actual pay including your skills, qualifications, and experience.  In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits. 

 
Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more. 

 
At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs. 

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 email recruitingUS@sunlife.com to request an accommodation.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

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All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.