Appeals & Complaints Specialist II

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

• Remote: This position is eligible to be fully remote

What will YOU be doing for us? Act as main point of contact and subject matter expert for receiving and resolving internal and external appeal and complaints related to assigned markets, including assigned specialty markets, and provide support for various assigned projects and initiatives as directed by the Manager and Supervisor. Provide appropriate proactive communication to internal and external team members regarding markets to ensure efficient and compliant operations.

What will YOU be working on every day?

• 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.

• Document all appeal, complaint, and grievance activity.

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

• Participate in and serve as lead for department projects such as implementations, system testing and upgrades, documentation updates.

• Act as liaison between the appeals department and clients for assigned markets.

• Complete analysis and trending for all activity in assigned markets to achieve overall client and department objectives.

• Act as the subject matter expert for assigned markets: answering questions to internal and external contacts and resolving matters that may fall outside of the established workflows.

• Act as a back-up to the Appeals Specialist III.

• Assist the Manager, Supervisor, Team Lead and Quality Analyst with tasks related to policy and procedure creation, training materials, capturing reporting requirements and other projects as requested.

• Participate in client and state audits.

• Regularly provides input for client and internal meetings, joining as a SME when needed.

• 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.

• Support additional projects as directed.

• Provide regular feedback about processes and system usage to help management identify opportunity areas to increase efficiencies.

• Participate in the upgrade, holiday and client weekend rotation.

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

• Knowledge of, and Ability to Complete all Functions of an Appeals Specialist

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

  • High school diploma or equivalent required

• Required Level of Experience

  • 3 or more years of job related experience (such as billing, problem solving, researching, etc.), or related experience

  • 2 – 3 years of job related experience interacting with customers and clients

• Required Knowledge, Skills, and Abilities

  • Strong verbal and written communication skills.

  • Ability to work autonomously

  • Good problem solving and decision making abilities.

  • Ability to adapt to changing priorities quickly.

  • Ability to successfully have conversations with others regarding challenging/sensitive topics.

  • 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.

  • Strong typing skills.

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

• Preferred Level of Education, License, and/or Certificates

  • Post high school education

• Preferred Level of Experience

  • Previous experience as an Appeals Specialist or similar role.

  • Previous experience working with clients

  • 2 plus years previous experience in working with managed care. or prior job related experience (Dental Assistant, Dental front office, or health/dental insurance accounts receivable and or billing operations)

• Preferred Knowledge, Skills, and Abilities

  • Experience working in a dental environment.

  • Strong typing skills.

  • Ability to resolve complex problems.

  • Ability to successfully have conversations with others regarding sensitive topics.

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:

$40,300.00 - $60,451.00

Compensation Midpoint:

$50,376.00