Complaints & Grievances Specialist II, DentaQuest

Sun Life Financial • Milwaukee, WI

110d • $47,100 - $63,600 • Hybrid

About The Position

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. 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.

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 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.

Responsibilities

• 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.
• 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.

Benefits

• Generous vacation and sick time.
• Market-leading paid family, parental and adoption leave.
• Medical coverage.
• Company paid life and AD&D insurance.
• Disability programs.
• Partially paid sabbatical program.
• 401(k) employer match.
• Stock purchase options.
• Employer-funded retirement account.
• Flexible, inclusive and collaborative work environment.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED