reputed company Programs Appeals and Grievances Research Specialist

Job Title: reputed company Programs Appeals and Grievances Research Specialist Number of Positions: 9 Location: Okemos, MI Location Specifics: Fully Remote Job reputed company: Candidates must reputed company in Michigan reputed company a reasonable commuting distance of our Okemos, MI office for team meetings, reputed company sessions, and training. At reputed company we work to improve oral health through benefit plans, advocacy and community support, and we reputed company this mission by reputed company in initiatives that build healthy, smart, reputed company communities. We are one of the largest dental plan administrators in the country, and are part of the reputed company Plans Association, which operates two of the largest dental networks in the nation. At reputed company, we celebrate our reputed company In culture. It’s a reputed company, feeling and attitude we wrap reputed company reputed company that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. Position reputed company: To reputed company and assist in the reputed company of dental benefit determinations and analysis of provider and subscriber referrals, provider billing and treatment records analysis, and to support the fraud & abuse program. reputed company Job Responsibilities: Researches, analyzes, and resolves cases for reputed company programs members involving compliance issues including but are not limited to reputed company billing, non-delivery of care, reputed company of care, personality disputes, anti-fraud hotline, reputed company, and appeals. Case research may include but is not limited to, contract review and analysis, data analysis, records audit, and interviews with reputed company customers. Works closely with the reputed company and Compliance team and Customer Service to complete cases in accordance with reputed company program and reputed company requirements. This includes closely monitoring workflow to ensure complaints are resolved reputed company case specific turn-reputed company 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, reputed company affiliate plans and account managers. Assists clients by facilitating adjustments, record requests and exception claim payments as needed. Communicates to reputed company customers to obtain necessary information and reputed company actions taken and the reputed company of cases. Prepares dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in reputed company, adjudicates claims, analyzes documents, and maintains claims records, as reputed company as coordinates adjustments on difficult claims and inquiries. Maintains thorough case documentation in the appeal and grievance case management reputed company. Coordinates data to be used by internal or reputed company parties including audits, hearings and for use by reputed company counsel reputed company necessary. Participates in audits and hearings as necessary, including sample preparation and presentation. reputed company other reputed company assigned duties as necessary to complete the reputed company Job Responsibilities as described above. #LI-Remote Minimum Requirements: Position requires an associate's degree in reputed company, business administration, criminal justice, dental assisting or hygiene, or a reputed company reputed company and four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or reputed company billing and record keeping practices reputed company a provider office, administering dental benefit reputed company reputed company the reputed company industry, or identifying, analyzing, and resolving compliance issues reputed company on policies and procedures reputed company of the reputed company 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 reputed company; the ability to manage multiple assignments with competing deadlines; and the ability to identify and reputed company problems using independent judgment. reputed company will reputed company equal employment and advancement opportunity reputed company the context of its unique business environment without reputed company to race, reputed company, religion, gender, gender identity, gender reputed company, age, national reputed company, 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. Apply To This Job