Complaints & Litigation Specialist
About The Position
As part of Global Customer Services & Operations, the Complaints & Grievances Specialist plays a critical role in creating positive experiences for MetLife customers by investigating and resolving complaints related to Dental (including DHMO) claims. This role requires strong analytical skills, sound judgment, and exemplary customer service to ensure timely and compliant resolution of grievances, complaints, and regulatory inquiries. Must be within a commutable distance of the Oriskany, NY, office location In office once a month for meetings
Requirements
- Knowledge of claims process
- High School Diploma or equivalent.
- Strong verbal and written communication skills.
- Proven customer service and conflict resolution abilities.
- Analytical skills for interpreting, evaluating claims, and analyzing reports & data.
Nice To Haves
- Minimum 5 years of experience in Dental.
- Knowledge of Dental terminology, procedures, and group plan contracts.
- Familiarity with systems such as NOVA, Dental SIR, MetCor, Insight platforms.
- Experience with MS Office (Excel, Powerpoint, CoPilot) a plus.
- Advanced knowledge of dental processes, procedure codes, and clinical terminology.
- Experience handling regulatory complaints.
- Ability to build relationships across departments and with external stakeholders.
- Sound business judgment and decision-making skills.
Responsibilities
- Investigation & Resolution Conduct thorough investigations of complaints and grievances, including issues such as Quality of Care, Coverage Disputes, Access to Care, and State Complaints.
- Review and identify complaint issues in conjunction with insurance plan provisions and applicable regulations.
- Determine corrective actions and resolution decisions, including claim reprocessing and provider/member reimbursement when applicable.
- Communication & Documentation Prepare comprehensive written responses addressing all concerns and corrective actions taken.
- Respond to telephonic inquiries from members and providers regarding complaint outcomes.
- Collaboration Collaborate with internal partner areas such as Claims Operations, Legal, Compliance, Network Development, and SIU.
- Refer cases to Legal, Litigation, or SIU departments when necessary.
- Compliance & Reporting Ensure all decisions and correspondence comply with plan contracts and state regulations.
- Maintain accurate and thorough complaint statistics for reporting and trending purposes.
- Monitor deadlines to meet time service standards and regulatory requirements.
Benefits
- Our U.S. benefits address holistic well-being with programs for physical and mental health, financial wellness, and support for families.
- We offer a comprehensive health plan that includes medical/prescription drug and vision, dental insurance, and no-cost short- and long-term disability.
- We also provide company-paid life insurance and legal services, a retirement pension funded entirely by MetLife and 401(k) with employer matching, group discounts on voluntary insurance products including auto and home, pet, critical illness, hospital indemnity, and accident insurance, as well as Employee Assistance Program (EAP) and digital mental health programs, parental leave, volunteer time off, tuition assistance and much more!
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
1,001-5,000 employees
