Appeal & Complaints Specialist

What are important things that YOU need to know about this role?

• Remote: This position is eligible for fully permanent remote work, allowing you to work from anywhere.

• Schedule: Monday to Friday, with typical day shift hours from 8:00 AM to 5:00 PM CST.

• Possible Weekend or Extended Hours: There may be occasional weekend or extended hours to meet contract deadlines or urgent requirements.

• Holiday Coverage: Some flexibility will be needed for holiday coverage depending on business nee

• Experience: Candidates should have prior experience in a dental or medical setting, along with a strong understanding of healthcare terminology..

What will YOU be doing for us? Review, analyze, and process complaints and appeals regarding dental and vision services. This position communicates with both internal and external entities to resolve complex payment disputes, quality of care issues, and requests for appeal regarding the denial of healthcare and/or dental services.

What will YOU be working on every day?

• Analyze, triage, investigate, research, and process standard and escalated appeals, complaints or state complaints from members, providers, health plans and state agencies.

• Communicate effectively with internal staff, members, and providers in the investigation and resolution of various appeals, complaints, and grievances.

• Accurate data entry and documentation of all appeal, complaint, and grievance activity for reporting and trending analysis.

• Accurately create formal correspondence to confirm receipt and provide resolution for member and provider complaints and appeal requests.

• Analyze and process all inbound mail scans and enterprise follow up communication to the Appeals department.

• Maintain strict compliance by utilizing Open Inventory Report, DASH and regulatory standards for appeal and grievance turnaround times and documentation requirements, including immediately notifying a member of department leadership or quality auditor of potential compliance risk.

• Participate in client audits and SKYGEN reaccreditation audits and interviews.

• Utilize all job aids, work instructions and step actions available to maintain current knowledge and understanding of existing process based on delegated responsibilities.

• Participate in job aid creation or updates in collaboration with ACG III and IV.

• Utilize assigned team specific chats while communicating effectively and in a professional manner as it relates to work assignments.

What qualifications do YOU need to have to be GOOD candidate?

• Required Level of Education, Licenses, and/or Certificates

  • High school diploma or equivalent required

• Required Level of Experience

  • 1 plus years of job related experience (such as billing, problem solving, researching, etc.)

  • 1 plus years of job related experience interacting with customers and clients

• Required Knowledge, Skills, and Abilities

  • Knowledge of general computer software; to include competencies in Outlook, Excel, and MS Word.

  • Ability to work overtime as needed.

  • Ability to communicate effectively and engage in a remote environment

  • Ability to work through challenging issues with others in a professional manner.

  • Accurate inventory management including data entry, time management and typing skills.

  • Strong verbal and written communication skills.

  • Ability to draft letters with strong attention to accuracy and grammar.

What qualifications do YOU need to have to be a GREAT candidate?

• Preferred Level of Experience

  • Previous experience processing appeals or complaints in a healthcare setting.

  • 2 years of prior job related experience (Dental Assistant, Dental Office Manager, Dental front office, or health/dental insurance, including managed care operations, accounts receivable and or billing)

• Preferred Knowledge, Skills, and Abilities

  • Ability to resolve complex problems.

  • Ability to work autonomously.

  • Experience working in a dental environment.

  • Ability to successfully have crucial conversations to resolve assigned appeals or complaints.

Compensation Range:

Compensation Midpoint: