Appeals & Complaints Specialist III

Important things YOU should know: 

• Fully Remote Opportunity. 

• 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.

• Candidates should have prior experience in a dental or medical setting, along with a strong understanding of healthcare terminology.

• Medicare/Medicaid experience strongly preferred. 

What will YOU be doing for us? Act as a main point of contact and subject matter expert for receiving and resolving standard and complex internal and external appeals and complaints, state complaints, (including assigned market(s)) and provide support for various assigned tasks and initiatives as directed by the Manager. Provide appropriate proactive communication to internal and external team members to reduce escalations overall and 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.

• Assist internal departments and clients with escalated provider and member concerns regarding open or resolved appeals or complaints.

• Act as a liaison and subject matter expert between the appeals department and clients for assigned market, escalated or complex issues.

• Act as primary resource for department projects.

• Act as primary resource for department technical support for appeals and complaints processing to include but not be limited to: appeals module configuration, letter template implementation, user acceptance testing. 

• Act as a SME to complete or drive participation in root cause analysis and trending for all activity in assigned markets to achieve overall client and department objectives Processes appeals, complaint, inquiry and continuation of care markets, as assigned.

• 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.

• Work collaboratively with internal departments to secure and maintain effective relationships.

• Work in collaboration with ACG IV as a resource in training new team members, which include shadowing, mentoring, and ensuring they have resources necessary to be successful

• Maintain strict compliance turnaround times

• At the direction of the Supervisor, collaborate with ACG IV and leadership to incorporate action plans to mitigate risk related to client program needs and escalations including team assignment adjustment and coverage for department processing.

• Update Supervisor, collaborate with ACG IV and leadership on significant issues, trends, and potential risk areas.

• Utilize effective diffusion techniques, when necessary, to ensure proper resolution is reached when handling internal and external conflicts.

• Assist ACG IV and Quality Analyst with tasks related to job aid creation, training materials, training efforts and capturing reporting requirements.

• Update existing resources used to maintain current knowledge and understanding of dental plans, coverage provided, and departmental processes

• Act as a subject matter expert for high priority items sent to the Appeals team; answering questions to internal and external contacts and resolving matters that may fall outside of the established workflows.

• Work collaboratively with the ACG IV, Supervisor, Manager and Quality Analyst to review, organize and prepare for annual, onsite, and periodic client audits and URAC preparedness.

• Act as back up for department ACG IV, Quality Analyst functions and when necessary Appeal Specialists.

• Participate in client audits and SKYGEN URAC reaccreditation and interviews.

• Regularly attend and participate in client and internal meetings as a representative of the Appeals team.

• Provide information and guidance for any incoming call center escalations.

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

• Act as a back-up to ACG IV to testing and upgrade meetings

• Act as a SME in collaboration with ACG IV during market go-lives

• Ability to back-up ACG IV to create letter template configuration, monitor SD+ Ticketing, configuration of ACGM under direction of Supervisor, and Compliance

• Ability to lead or host team huddles or meetings.

• In collaboration with ACG IV, conduct quality reviews of all new staff when acting 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

• 2+ years of complaints, appeals, and grievances processing for a managed care program, or related experience (such as billing, problem solving, researching, etc.).

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.

• Demonstrated ability to pay attention to detail.

• 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 in a related field.

Preferred Level of Experience

• Previous appeals experience in a healthcare. 

• 2 + years of related experience such as Dental front office, health/dental insurance, managed care operations, accounts receivable and or billing.

• Previous experience in a leadership role.

• Previous experience working with Medicare/Medicaid 

Preferred Knowledge, Skills, and Abilities

• Experience working in a dental environment.

• Advanced MS Office Suite and typing skills.

• Ability to resolve complex problems.

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