Job Description

The Grievance Coordinator is responsible for assisting with preparing dental records (charts and x-rays), opening new grievances, working with payer and dental board complaints. This position ensures that all grievances and appeals are processed timely and data entered accurately. The QM Coordinator plays a key role in maintaining member satisfaction, regulatory compliance, and quality improvement.

Responsibilities

• Receive, document, and acknowledge grievances and appeals within required timeframes.

• Investigate complaints, including research with dental offices, involving dental benefits, claims processing, provider services, and quality of care issues.

• Prepare dental records, which include patient/office history and dental ledgers, and clinical documentation.

• Collaborate with internal teams such as the Grievance Coordinator or Sr. Manager of QM to ensure proper hand-off of grievances for resolution.

• Respond, where needed, accurately and with proper grammar to various entities submitting complaints.

• Track and monitor open cases to ensure compliance with regulatory deadlines (e.g., state Department of Insurance, CMS, payer guidelines, and NCQA standards).

• Maintain detailed and accurate documentation in the grievance tracking system and prepare regular reports on trends and outcomes, as requested.

• Identify systemic issues or trends and recommend process improvements to enhance member, provider, and payer experiences.

• Support audits, compliance reviews, and quality improvement initiatives as needed.

• Educate teammates and others on grievance and appeals procedures to promote consistent handling and prevent recurrence of issues.

• Perform other tasks as needed to support the department.

Skills and Competencies:

• Strong analytical and investigative skills, with attention to detail.

• Excellent written and verbal communication skills.

• Working knowledge of dental benefits administration, utilization review, and provider relations.

• Ability to manage multiple priorities and meet strict deadlines.

• Proficiency with Microsoft Office and Adobe.

• Strong commitment to confidentiality, professionalism, and member advocacy.

Qualifications

• 1 year of experience in grievance or appeals or claims or customer services issue coordination, preferably in dental or health insurance.

• Familiarity with dental terminology, CDT codes, and dental claims processing is preferred.