Provides compliance oversight and operational guidance to management and staff responsible for resolving member appeals and grievances
Develops, maintains, and delivers training materials and job aids
Conducts comprehensive monthly quality and compliance audits of appeals and grievances
Develops and maintains departmental procedures, controls, and reference materials
Supports internal and external audits by coordinating requests, compiling audit samples and supporting evidence
Serves as a compliance and process subject matter expert during audits and meetings
Assists in assigning work and performing appeal and grievance reviews
Provides day-to-day compliance support to the appeals and grievances team

Bachelor’s degree in accounting, business administration, criminal justice, health care administration, dental assisting or hygiene, or a related field
Three years of resolving complaints in the dental insurance industry or six years of experience in a position requiring knowledge of dental office billing and record keeping practices
Previous experience supporting an anti-fraud/abuse program and/or audit/compliance monitoring activities preferred
Strong verbal and written communication skills
Strong analytical skills
Ability to work independently and as part of a team
Ability to manage multiple assignments with competing deadlines
Ability to identify and resolve problems using independent judgment

Government Programs Appeals and Grievances Compliance Specialist

Key skills