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Location

Wellesley, MA | United States

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Job 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.

Job Description:

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.
• 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.
• 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.

Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [email protected] to request an accommodation.

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:

02/05/2024

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.

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Job tags

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Salary