Job description

Here at LIBERTY our FLOSSify is simple. Find good people and help them shine!

The Grievances and Appeals (G&A) Analyst I will be responsible for investigating and resolving member, Health Plan Partner-member and network provider grievances and appeals.

• Identify, analyze and research both pre- and post-service denials for both members and providers to identify discrepancies, errors, etc. and to determine appropriate course(s) of action.
• Process all appeals within regulatory guidelines.
• Respond in writing to members and providers, making informed judgements on the proper application of members dental plan benefits, accurate adjudication of claims and referrals and other potential issues by conducting timely, thorough investigations of assigned grievances and appeals cases.
• Verify information related to data entry, claims submissions, authorizations and workflow processes to ensure timely reimbursement to members and providers when necessary.
• Demonstrate team-oriented attitude by following directions from Supervisor, interacting well with co-workers, accepting and following work rules and procedures, complying with corporate policies, goals and objectives, accepting constructive feedback and exhibiting initiative and accountability for their work.
• Interface with other internal and external entities, ensuring a positive and professional relationship.
• The Grievances and Appeals Analyst I will also be responsible for occasional intake of all member and provider grievances and appeals.

Distinguishing Characteristics for G&A Analyst II
The Grievance and Appeals Analyst II will act as a subject matter expert to the Grievance and Appeals Analyst I regarding grievances and appeals and will collaborate within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.

• Performing the job duties of the Grievance and Appeals Analyst I position, detailed above.
• Receive and respond to department staff questions and concerns, demonstrating sound judgement and communication clear instructions to team members.
• Assist with any training that department staff members may require.
• Follow and implement all directive, policies and procedures.
• Identify areas of concern and assist with the development and implementation a strategy for the department to reach its goals.
• Respond in writing to all levels of grievances and appeals, including fair hearings.

Distinguishing Characteristics for G&A Analyst III
The Grievance and Appeals Analyst III will be responsible for investigating and resolving highly complex member, Health Plan Partner-member and network provider grievances and appeals such as disputes involving high reimbursement amounts and/or complex quality of care cases.

• Respond to all levels of regulatory complaints, such as those from the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) or Department of Insurance (DOI).
• Investigate and perform the job duties as the Grievance Analyst I and II, detailed above.
• Monitor all incoming notices of requests for fair hearings or requests for Health Plan Information (RHPI) from the DMHC, DHCS or DOI.
• Communicate directly with members, providers and Health Plan partners when necessary to obtain additional information and/or providing updates regarding the progress of active and open cases.
• Assist with monitoring daily operations of the Grievance Team when a Team Lead, Supervisor or Manager is out of the office.
• Aid the Supervisor/Manager with developing and maintaining grievance policies, procedures and compliance assessments.
• Attend monthly/quarterly Grievance Committee meetings. Prepare and present agenda items as assigned by Supervisor/Manager.

Education and/or Experience:

• Analyst I
• High School Diploma or GED required.
• Minimum of 3 years of dental background required.
• Dental Insurance Plan experience highly preferred.
• Experience in a Quality Management Department preferred.
• Minimum 2 years office administrative support in healthcare preferred.

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Analyst II*

• High School Diploma or GED required
• Minimum of 5 years of dental background required.
• Minimum of 1 year grievance and appeals experience required.
• Dental Insurance Plan experience highly preferred.
• Experience in a Quality Management Department preferred.

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Analyst III*

• High School Diploma or GED required; College degree preferred
• Minimum 3 years of dental background required
• Minimum 2 years experience processing complex case reviews and resolutions required
• Minimum 2 years experience handling regulatory complaints including State Fair Hearings is required
• Minimum 2 years experience with verbal and written documentation, preferably related to dental benefits administration, is required

Specific Skills/Knowledge (All Levels):

• Excellent time management skills are required, along with the ability to meet strict internal and regulatory deadlines; while working independently in a fast-paced environment and maintaining superior work quality.
• Intermediate knowledge in Microsoft Word and Excel.
• Excellent written communication skills, with the ability to draft professional business correspondence directed toward a wide variety of audiences, from laymen to doctors, is required.
• Strong verbal communication and customer service skills, particularly as it relates to processing member and provider grievances and appeals.
• Demonstrate ability to work independently, prioritize workload and maintain strong business relationships.
• Strong working knowledge of applicable laws and regulations, including current appeals guidelines established by the Centers for Medicare and Medicaid Services (CMS), and the ability to research Medicare and Medicaid regulations to ensure compliance and protect the company from sanctions, enforcement actions and penalties.
• Availability to work overtime when required.

Additional Specific Skills/Knowledge for G&A Analyst III:

• Thorough knowledge of Microsoft Word, Outlook and Excel is required; knowledge of HSP is preferred.
• Thorough knowledge of the principles and practices of managed health care and commercial business regulations is preferred.
• Knowledge of and experience reviewing dental records is required.

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Compensation Statement: _*
In the spirit of pay transparency, we are excited to share the base rate of pay for this position is $18.50 - $25.95 per hour, exclusive of fringe benefits or potential bonuses. If you are hired at LIBERTY, your final rate of pay will be determined based on factors such as geographic location, skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider internal equity of our current team members as a part of any, final offer. Please keep in mind that the range mentioned above is the full base salary range for the role. Hiring at the maximum of the range would not be typical in order to allow for future & continued salary growth. We also offer a generous benefits package, and we look forward to sharing all of these details soon.

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Environment and/or Physical Factors: _*
Work is generally performed within an office environment, with standard office equipment available. Sedentary work involves extensive sitting, typing, close range vision most of the time.

Sponsorship and Relocation Specifications:
LIBERTY Dental Plan is an Equal Opportunity Employer / VETS / Disabled.
No relocation assistance or sponsorship available at this time.

Job Type: Full-time

Pay: $18.50 - $25.95 per hour

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