Appeals & Complaints Specialist I

Important things YOU should know:

• Fully Remote Role
• Schedule: Monday - Friday - 8:00am - 5:00pm CST
• Holiday & Saturday Rotation
• Flex Schedule Potential

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?

• Analyze, research, and process appeal requests from members and providers regarding denied requests for clinical services and/or payment.
• Analyze, research, and resolve complaints and grievances filed by members or providers regarding unsatisfactory aspects of dental and/or vision benefit provisions or care.
• Communicate effectively with clients, members, and providers in the investigation and resolution of various appeals, complaints, and grievances.
• Document all appeal, complaint, and grievance activity for reporting and trending analysis.
• Create formal correspondence to confirm receipt and provide resolution for member and provider complaints and appeal requests.
• Analyze and process all inbound mail and email communication to the Appeals department.
• Maintain strict compliance and regulatory standards for appeal and grievance turnaround times and documentation requirements.
• Utilize resources available to maintain current knowledge and understanding of dental plans and coverage provided.

Additional Responsibilities:

• Provide information and guidance for any incoming call center inquiries.
• Provide regular feedback about processes and system usage to help management identify opportunity areas to increase efficiencies.

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+ years of job related experience such as accounting, billing or insurance.
  • 1+ 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 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.

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

• Preferred Level of Experience
  • Previous appeals experience in a healthcare setting.
  • 2 + years of prior job related experience such as Dental front office, health/dental insurance, 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.

The salary range and midpoint is listed below for your reference. Please keep in mind that your education and experience along with your knowledge, skills and abilities are taken into consideration when determining placement within the range.

Compensation Range:

Compensation Midpoint: