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.
PRIMARY JOB RESPONSIBILITIES: (NOT an exhaustive task list)
Investigate and resolve member appeals in accordance with State and/or Plan guidelines.
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 submitted by plan (when DQ is secondary)
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 and participate in 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.
Investigate and resolve Level II and Level III requests (TennCare market only).
Comply with and resolve proof of compliance and directives.
Identify when Maximus packet is necessary based on Medicare guidelines and assemble and prepare packet.
Identify and prepare when an ODI (Ohio Department of Insurance) or IRE (independent review entity) packets are required.
Take the lead in working with other internal departments/management team to ensure that any issues raised in the complaint/grievance that are substantiated are brought to the appropriate people's attention.
Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.
Identify and resolve issues that are unusual and not consistent with standard CGA workflows.
Attend market meetings to represent C&G and share any new issues/changes that may be impactful to others in C&G.
Establish and maintain professional relationships with Plan contacts.
Contact involved provider office to obtain information to properly review the case. Document provider's/staff's perception of the member's concerns / issues.
Proficiently trained to handle provider appeals and provides assistance to C&G Level 1
Ability to identify and resolve issues that are unusual and not consistent with standard CGA workflows
Document all complaints/grievances/appeals in department tracking system
Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
Communicate ways to improve processes and procedures to management.
Other duties as assigned.
High School Diploma or GED required.
1 year of C&G experience with demonstrated success in C&G Specialist I or 2 years' experience in claims, customer service, provider network or another operational function.
Proficient with general computer software including Microsoft Excel, Word and Outlook.
Excellent verbal, written, interpersonal, organizational and communication skills.
Excellent research skills with ability to identify underlying issue(s) not articulated
Ability to remain calm and focused in a high pressure/high workload environment
Ability to work in a high stress environment.
Ability to prioritize and organize multiple tasks with tight deadlines.
Ability to remain organized with multiple interruptions.
Ability to work overtime as needed or required to meet business objectives.
1 year of experience in a higher-level role such as Lead or Supervisor role.
Bachelor's degree in Business Administration/Management or a related field, or equivalent experience in healthcare management.
11100 West Liberty Drive, Milwaukee, Wisconsin 53215