To learn more about how Willamette Dental Group is keeping our employees safe, please visit https://willamettedental.com/safety/
The Grievance and Appeals Coordinator specializes in facilitating grievances, appeals and care coordination for members. This position has in depth knowledge of contractual and compliance regulations such as; but not limited to, Oregon Administrative Rules (OARs) and regulations relating Centers for Medicare and Medicaid Services (CMS) and grievance, appeal and care coordination best practices.
Essential Position Functions
- Respond to escalated requests from members regarding formal grievances, appeals or care coordination.
- Maintains detailed files on each appeal and grievance.
- Ensures demands or needs of the member are clearly understood through verbal or written communication confirmation.
- Perform fact based, root cause analysis and clinical review on concerns received, and addresses concerns appropriately in a timely manner ensuring compliance. Perform analysis on complaints related to sensitive accounts and strategic relationships and collaborates with appropriate stakeholders.
- Address inquiries and grievances through social media channels & email that require thoughtful and careful written responses.
- Collaborate with management and external partners (e.g. social or case workers, etc.) regarding patient behavior management strategies and care coordination.
- Write clear, appropriate and concise communications to members related to all aspects of facilitating grievances, appeals and care coordination for members as needed.
Non-Essential Position Functions
- May provide specialized work instruction and guidance to less experienced members of the team.
- May assist with reporting, maintenance and training for the complaint management system.
- As needed, assist with phone coverage to meet service level requirements, catastrophic attendance or natural disaster events.
High School Diploma or equivalent and a minimum of two years of customer service experience; or any equivalent combination of education and/or experience which leads to the ability to perform the essential functions of the position. Specialized experience in grievances and appeals as related to Insurance and Healthcare services required.
- Dental terminology and procedures.
- Standard office equipment including personal computers, database entry and Microsoft suite of applications to communicate and convey information.
- Insurance policies, contracts and consumer rights.
- Oregon Administrative Rules (OARs) and regulations overseen by Centers for Medicare and Medicaid Services (CMS) relating to services provided by Willamette Dental Group and timelines necessary to ensure compliance.
- Verbal and written communications and being able to diffuse difficult conversations.
- Decision-making, problem-solving and organizational agility.
- Keyboarding including 10 key.
Provide outstanding customer service.
Identify complaints, negotiate solutions, communicate the company's position and support the appropriate outcome or provide alternative avenues to appeal. .
Navigate members complex care needs using resources within or outside the organization.
Relate to others in a respectful, constructive manner.
Embrace and promote company's model of practicing dentistry.
Uphold and exemplify the company's core values. Maintain clear and open lines of communication between the Practices and Member Services.
Understand and clearly communicate to members how to access and utilize plan benefits, and demonstrate a clear understanding of contract compliance.
Demonstrate cultural competency and interact with members from very diverse backgrounds and cultures.
- A stable, dentist-owned private company with an eye on the future.
- Excellent benefits, including paid time off, 401K with generous company match, and medical dental, life and disability insurances. Tuition reimbursement.
- A culture of inclusivity and respect in line with our core values of Health, Compassion, Innovation and Integrity.
- Supportive community outreach dollars and encouragement to volunteer.
- Thorough employee orientation and onboarding.
- A provider and employer of choice in the Northwest for 50 years.
- Dental insurance + providers in over 50 general and specialty offices in OR, WA and ID.
- Dedicated to proactive care to facilitate the best possible outcomes.
Willamette Dental Group is an equal opportunity employer.
We evaluate qualified candidates without regard to race, color, religion, sex, national origin, veteran status and other protected characteristics.
This job description is not meant to be an all-inclusive list of duties and responsibilities, but constitutes a general definition of the position's scope and function in the company.
This position may be exposed to PHI in the course of his/her duties, and will handle protected information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
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