• Job Description

  Req#: 1230

  The Regulatory Complaint Coordinator responds to complaints initiated by regulatory agencies and the Centers for Medicare and Medicaid Services (CMS) and oversees the complaint response process to facilitate timely resolutions and responses. This position participates in regulatory and group audits, and in the analysis of regulatory complaint drivers.

  *This position is a hybrid position that would require the employee to report to the Alpharetta, GA office as needed.

  Qualifications

  • 3 or more years’ experience with a High School Diploma or GED.
  • Experience in customer service, provider service, health service, or dental in a managed care or health care environment handling escalated or complex issues in government and commercial lines of business.
  • 3 or more years’ experience with researching and resolving inquiries received from State and Federal agencies.
  • Knowledge of how to research and resolve inquiries received from State and Federal agencies.
  • Proficient in using Microsoft Office products specifically using Excel formula functions and formatting functions.
  • Strong attention to detail, problem solving and critical thinking skills, with the ability to conduct research and identify steps required to resolve issues and follow through to completion.
  • Strong organizational and time management skills.
  • Excellent verbal and written communication skills with the ability to engage with a wide variety of audiences.
  • Six Sigma Green Belt certification a plus!

  Base Pay Information
  
  The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental’s assessment of the candidate’s knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. $41,000 - $83,200

  Responsibilities

  • Acts as a subject matter expert (SME) for all complaint types.
  • Records and resolves all provider and member complaints and inquiries initiated by local, State and Federal regulatory agencies, as well as governmental contracted entities into company tracking system.
  • Identifies the root causes of executive complaints and works with the applicable operational departments to implement an appropriate resolution; departments include but are not limited to: Finance, Enrollment, Claims, Provider Relations & Contracting, Member Services, Medical Management, and Product Management.
  • Resolves complaints for the CMS and regulatory agencies.
  • Coaches the Grievance and Appeals (G&A) specialists and coordinators in response to customer issues, complex inquiries, and tricky situations.
  • Communicates resolutions to the requesting agency via telephone or written correspondence.
  • Assists the department in maintaining, tracking, resolution outcome and following up on all regulatory directives received from governmental agencies.
  • Extracts complaints data to identify trends, patterns, and performs appropriate analysis and translation of such data.
  • Participates in client and regulatory audits.
  • Identifies member problems, member education needs and/or trends, reports this information to G&A leadership and provides a recommended resolution based on the analysis of data.
  • Stays abreast of new and/or emerging regulatory guidelines, standards, business changes, etc. affecting the member advocacy and/or grievance and appeals process.

• About the company

  The Delta Dental Plans Association is composed of 39 independent Delta Dental member companies operating in all 50 states, the District of Columbia and Puerto Rico.

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