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:

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

Complaint & Grievance Resolution

• 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

• Other duties as assigned.

Minimum Job Requirements

• High School Diploma or GED required.
• 1 year of C&G experience with demonstrated success …