Complaints & Grievances Specialist II, DentaQuest

Sun Life•Milwaukee, WI

21d•Hybrid

About The Position

The Complaints & Grievances Specialist II handles 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. Accountable for daily interaction with assigned market/client contacts, as well as various internal departments. This position also ensures 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 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.

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.
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

Benefits

At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program.
Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account.
Enjoy a flexible, inclusive and collaborative work environment that supports career growth.
We’re proud to be recognized in our communities as a top employer.
Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.

Stand Out From the Crowd

Upload your resume and get instant feedback on how well it matches this job.

Upload and Match Resume