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{"uid":"1781950793234936704","crypted":"RFppK2RibjRVV3JOWEdpYlA0MzRLS1FSMWc9PQ==","location":"Oriskany, NY","address":"4930 Griffin Groves Apt. 013","zip":"33264-5003","country":"US","title":"Complaints & Litigation Specialist","slug":"complaints-and-litigation-specialist","sumary":" Must be within a commutable distance of the Oriskany, NY, office location \r\n In office once a month for meetings \r\n Key Responsibilities: \r\n Investigation & Resolution \r\n \r\n Conduct thorough investigations of complaints and grievances, including issues such as...","company":"MetLife","description":"<p> <p> Must be within a commutable distance of the Oriskany, NY, office location <\/p> <p> In office once a month for meetings <\/p> <p> Key Responsibilities: <\/p> <p> Investigation & Resolution <\/p> <ul> <li> <p> Conduct thorough investigations of complaints and grievances, including issues such as Quality of Care, Coverage Disputes, Access to Care, and State Complaints. <\/p><\/li> <li> <p> Review and identify complaint issues in conjunction with insurance plan provisions and applicable regulations. <\/p><\/li> <li> <p> Determine corrective actions and resolution decisions, including claim reprocessing and provider\/member reimbursement when applicable. <\/p><\/li><\/ul> <p> Communication & Documentation <\/p> <ul> <li> <p> Prepare comprehensive written responses addressing all concerns and corrective actions taken. <\/p><\/li> <li> <p> Respond to telephonic inquiries from members and providers regarding complaint outcomes. <\/p><\/li><\/ul> <p> Collaboration <\/p> <ul> <li> <p> Collaborate with internal partner areas such as Claims Operations, Legal, Compliance, Network Development, and SIU. <\/p><\/li> <li> <p> Refer cases to Legal, Litigation, or SIU departments when necessary. <\/p><\/li><\/ul> <p> Compliance & Reporting <\/p> <ul> <li> <p> Ensure all decisions and correspondence comply with plan contracts and state regulations. <\/p><\/li> <li> <p> Maintain accurate and thorough complaint statistics for reporting and trending purposes. <\/p><\/li> <li> <p> Monitor deadlines to meet time service standards and regulatory requirements. <\/p><\/li><\/ul> <p> Required Qualifications: <\/p> <ul> <li> <p> Knowledge of claims process <\/p><\/li> <li> <p> High School Diploma or equivalent. <\/p><\/li> <li> <p> Strong verbal and written communication skills. <\/p><\/li> <li> <p> Proven customer service and conflict resolution abilities. <\/p><\/li> <li> <p> Analytical skills for interpreting, evaluating claims, and analyzing reports & data. <\/p> * <\/li><\/ul> <p> Preferred Qualifications: <\/p> <ul> <li> <p> Minimum 5 years of experience in Dental. <\/p><\/li> <li> <p> Knowledge of Dental terminology, procedures, and group plan contracts. <\/p><\/li> <li> <p> Familiarity with systems such as NOVA, Dental SIR, MetCor, Insight platforms. <\/p><\/li> <li> <p> Experience with MS Office (Excel, Powerpoint, CoPilot) a plus. <\/p><\/li> <li> <p> Advanced knowledge of dental processes, procedure codes, and clinical terminology. <\/p><\/li> <li> <p> Experience handling regulatory complaints. <\/p><\/li> <li> <p> Ability to build relationships across departments and with external stakeholders. <\/p><\/li> <li> <p> Sound business judgment and decision-making skills. <\/p><\/li><\/ul> <p> Equal Employment Opportunity\/Disability\/Veterans <\/p> <p> If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process. <\/p> <p> MetLife maintains a drug-free workplace. <\/p>","tags":"","url_out":"https:\/\/jooble.org\/desc\/-1781950793234936704?ckey=aflac&rgn=-1&pos=15&groupId=52918&elckey=-1993112835424055308&pageType=20&p=1&sid=5493685306379771620&jobAge=90&relb=100&brelb=100&bscr=14425.606100220137&scr=14425.606100220137&searchTestGroup=1_1389_3&iid=5955469477150958057","salary":"","currency":"USD","pubDate":1766551355,"expDate":1771735355}Anon7 - 2022
AnonSec Team