[Hiring] Government Programs Appeals and Grievances Research Specialist @Delta Dental of Michigan

Role 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.

• Researches, analyzes, and resolves cases for government programs members involving compliance issues including but not limited to:
  • Balance billing
  • Non-delivery of care
  • Quality of care
  • Personality disputes
  • Anti-fraud hotline
  • Internal referrals
  • Appeals
• Case research may include:
  • Contract review and analysis
  • Data analysis
  • Records audit
  • 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.
• Monitors workflow to ensure complaints are resolved within case specific turn-around times.
• Performs case reviews for clients who have elected to handle their own appeals and grievances.
• Communicates to internal and external customers to obtain necessary information and relay actions taken and the resolution of cases.
• Prepares dental claims for appropriate determinations.
• Maintains thorough case documentation in the appeal and grievance case management system.
• Coordinates data for audits, hearings, and legal counsel when necessary.
• Participates in audits and hearings as necessary, including sample preparation and presentation.
• Performs other related assigned duties as necessary to complete the Primary Job Responsibilities.

Qualifications

• Associate's degree in accounting, business administration, criminal justice, dental assisting or hygiene, or a related field.
• Four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or dental office billing and record keeping practices.
• Experience in administering dental benefit contracts within the insurance industry or identifying, analyzing, and resolving compliance issues.
• Previous experience supporting an anti-fraud/abuse program preferred.
• Knowledge of word processing, spreadsheet, and database applications.
• Strong verbal and written communication skills.
• Strong analytical skills.
• Ability to work independently and as part of a team.
• Ability to manage multiple assignments with competing deadlines.
• Ability to identify and resolve problems using independent judgment.

Requirements

• Equal employment and advancement opportunity 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.