$55-60K

1 day a week in office - Worcester

1 day a week on the road (mileage reimbursed)- anywhere in MA

3 days remote

Position Summary:

The Grievance and Appeals Specialist will handle inquiries, complaints, grievances, and appeals related to dental claims and services. This role involves investigating, documenting, and resolving cases while adhering to company policies, regulatory requirements, and quality standards. The ideal candidate is highly organized, detail-oriented, and passionate about helping others.

Key Responsibilities:

• Grievance Resolution: Investigate and resolve patient and provider grievances related to dental services, billing, and claims. Ensure timely and accurate communication throughout the process.
• Appeals Management: Review, analyze, and process appeals submitted by patients, providers, or third parties. Make decisions based on company guidelines, policies, and applicable regulations.
• Documentation: Maintain thorough and accurate records of grievances and appeals, including case summaries, correspondence, and outcomes. Prepare detailed reports for management review.
• Compliance: Ensure compliance with applicable laws, regulations, and company standards, including HIPAA, state insurance laws, and quality assurance protocols.
• Collaboration: Work closely with clinical teams, customer service, claims, and legal departments to gather necessary information and resolve cases effectively.
• Communication: Provide clear and empathetic communication to patients and providers regarding case status, resolution timelines, and outcomes.
• Process Improvement: Identify trends in grievances and appeals, providing feedback and recommendations to improve processes, reduce issues, and enhance customer satisfaction.

Qualifications:

• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, or a related field preferred.
• Minimum of 2 years of experience in grievance and appeals, claims processing, or related roles, preferably in dental or healthcare.
• Strong understanding of dental terminology, insurance policies, and claims processing.
• Excellent verbal and written communication skills.
• Ability to manage multiple cases simultaneously while meeting deadlines.
• Strong problem-solving and analytical skills.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook) and claims management software.
• Knowledge of HIPAA regulations and compliance requirements.