Government Programs Appeals and Grievances Research Specialist

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Number of Positions:

Location:

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Job Summary:

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training. 

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. 

Position Description:

To direct and assist in the resolution of dental benefit determinations and analysis of provider and subscriber referrals, provider billing and treatment records analysis, and to support the fraud & abuse program.

Primary Job Responsibilities:

• Researches, analyzes, and resolves cases for government programs members involving compliance issues including but are not limited to balance billing, non-delivery of care, quality of care, personality disputes, anti-fraud hotline, internal referrals, and appeals. Case research may include but is not limited to, contract review and analysis, data analysis, records audit, and interviews with external customers.
• Works closely with the Legal and Compliance team and Customer Service to complete cases in accordance with government program and client requirements. This includes closely monitoring workflow to ensure complaints are resolved within case specific turn-around times, applicable rights are provided, and requirements for manner and content of notice to customers are met.
• Performs case reviews for clients who have elected to handle their own appeals and grievances communicating directly with clients, Delta Dental affiliate plans and account managers. Assists clients by facilitating adjustments, record requests and exception claim payments as needed.
• Communicates to internal and external customers to obtain necessary information and relay actions taken and the resolution of cases.
• Prepares dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place, adjudicates claims, analyzes documents, and maintains claims records, as well as coordinates adjustments on difficult claims and inquiries.
• Maintains thorough case documentation in the appeal and grievance case management system.
• Coordinates data to be used by internal or external parties including audits, hearings and for use by legal counsel when necessary. Participates in audits and hearings as necessary, including sample preparation and presentation.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

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Minimum Requirements:

Position requires an associate's degree in accounting, business administration, criminal justice, dental assisting or hygiene, or a related field and four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or dental office billing and record keeping practices within a provider office, administering dental benefit contracts within the insurance industry, or identifying, analyzing, and resolving compliance issues based on policies and procedures outside of the insurance industry. Previous experience supporting an anti-fraud/abuse program preferred. Will accept any suitable combination of education, training, or experience.
Position also requires knowledge of word processing, spreadsheet, and database applications; strong verbal and written communication skills; strong analytical skills; the ability to work independently and as part of a team; the ability to manage multiple assignments with competing deadlines; and the ability to identify and resolve problems using independent judgment.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.