Complaints & Grievances Specialist Ii, Dentaquest - Wellesley Hills, United States - Sun Life

Sun Life

Verified Company

Wellesley Hills, United States

1 week ago

Posted by:

Mark Lane

beBee recruiter

Description

You are as unique as your background, experience and point of view. Here, you'll be encouraged, empowered and challenged to be your best self.

You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you.

Your leaders will inspire and help you reach your potential and soar to new heights.

Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do.

Discover how you can make a difference in the lives of individuals, families and communities around the world.

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.

Complaint & Grievance Resolution

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
Member Complaints/Grievances

submitted by plan (when DQ is secondary)

Provider Complaint
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 scheduling State Fair Hearing reviews
Assemble necessary information for the plan so they may appropriately investigate member appeals/complaints when we are not delegated.
Comply with and resolve proof of compliance and directives.
Contact involved provider office to obtain information to properly review the case. Document provider's/staff's perception of the member's concerns / issues.
Document all complaints/grievances/appeals in department tracking system
Other duties as assigned.

Minimum Job Requirements

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.

The pay range for this position is $43, ,60

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work.

Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

Job Category:

Customer Service / Operations

Posting End Date:

11/07/2024

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.