Appeals & Complaints Specialist II

Important things YOU should know:

• Fully Remote!

• Schedule: Monday to Friday - 8:00 AM to 5:00 PM CST.

• Possible Weekend/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 need.

• 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? 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?

• 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.

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

• Act as a SME for assigned markets, answer questions from internal/external business partners, including escalations and serve as a preceptor for training.

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

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

• Assist ACG III & IV in collaboration with Quality Analyst with tasks related to job aid creation, training materials, capturing reporting requirements and other projects as requested.

• Participate in client audits and reaccreditation interviews.

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

• Act as a SME (Subject Matter Expert) while overseeing daily Compliance Closure, utilizing Open Inventory Report and DASH to maintain strict compliance and regulatory standards for appeal and grievance turnaround times and documentation requirements. This includes notifying leadership or quality auditor of any potential compliance risk.

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

• In collaboration with ACG III, maintain job aid updates in timely manner, seeking approval from market SMEs and ACG IV

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

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 and/or oversee testing, upgrades, and client holiday weekend rotation.

• Participate in market go-lives.

• In collaboration with ACG III & IV, conduct quality reviews of all new staff when assigned as preceptor, staff on trackers or related to correction action findings

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

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

  • 2+ years of job related experience interacting with customers and clients.

• Required Knowledge, Skills, and Abilities

  • Advanced knowledge in MS Word, Excel and Outlook.

  • Ability to compose communication letters efficiently, effectively and accurately.

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

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

  • Ability to communicate effectively and engage in a remote environment.

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

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

  • Post secondary education.

• 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

  • Experience working in a dental environment.

  • Strong typing skills.

  • Ability to resolve complex problems.

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