Hiring: Claim Processing Representative, DentaQuest (Remote)

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You’ll work with dynamic colleagues – experts in their fields – who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you’ll have new and exciting opportunities to make life brighter for our Clients – who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:
Location: We welcome applicants from anywhere in the U.S.

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.

The opportunity: 

The Complaints & Grievances Specialist II is responsible for the investigation and resolution of complaints, grievances and member appeals based upon specific regulatory requirements.  In addition, responsible for the assembly and preparation of Maximus packets, State Fair Hearing packets as well as coordination and participation in State Fair Hearings.  Responsible for daily interaction with assigned market/client contacts, as well as various internal departments.  This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

How you will contribute: 

Investigate and resolve member appeals in accordance with State and/or Plan guidelines.
Investigate and resolve complaints and grievances in accordance with State and/or Plan guidelines. Ensure all components of the grievance/complaint are researched and addressed.  Complaints/grievances that this role is responsible for include: Member Complaints/Grievances, Member Complaints/Grievances submitted by plan (when DQ is secondary), Provider Complaint, SDOH (State Department of Health) complaints, DOI (Department of Insurance) complaints, BBB (Better Business Bureau) complaints, and Executive complaints

Prepare State Fair Hearing packets and coordinate and participate in State Fair Hearing reviews
Assemble necessary information for the plan so they may appropriately investigate member appeals/complaints when we are not delegated.
Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately.  Manage workflow to meet department, Plan, State, and company goals and deadlines.
Investigate and resolve Level II and Level III requests (TennCare market only).
Comply with and resolve proof of compliance and directives.
Identify when Maximus packet is necessary based on Medicare guidelines and assemble and prepare packet.

Identify and prepare when an ODI (Ohio Department of Insurance) or IRE (independent review entity) packets are required.
Take the lead in working with other internal departments/management team to ensure that any issues raised in the complaint/grievance that are substantiated are brought to the appropriate people’s attention.
Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.
Identify and resolve issues that are unusual and not consistent with standard CGA workflows.
Attend market meetings to represent C&G and share any new issues/changes that may be impactful to others in C&G.
Establish and maintain professional relationships with Plan contacts.

Contact involved provider office to obtain information to properly review the case. Document  provider’s/staff’s perception of the member’s concerns / issues.
Proficiently trained to handle provider appeals and provides assistance to C&G Level 1
Ability to identify and resolve issues that are unusual and not consistent with standard CGA workflows
Document all complaints/grievances/appeals in department tracking system
Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
Communicate ways to improve processes and procedures to management.
Other duties as assigned.

What you will bring with you: 

High School Diploma or GED required.
1 year of C&G experience with demonstrated success in C&G Specialist I or 2 years’ experience in claims, customer service, provider network or another operational function.
Proficient with general computer software including Microsoft Excel, Word and Outlook.
Excellent verbal, written, interpersonal, organizational and communication skills.
Excellent research skills with ability to identify underlying issue(s) not articulated
Ability to remain calm and focused in a high pressure/high workload environment
Ability to work in a high stress environment.
Ability to prioritize and organize multiple tasks with tight deadlines.
Ability to remain organized with multiple interruptions.
Ability to work overtime as needed or required to meet business objectives.

Preferred Qualifications

1 year of experience in a higher-level role such as Lead or Supervisor role.

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you!

Life is brighter when you work at Sun Life

Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
A flexible work environment with a friendly, caring, collaborative and inclusive culture
Great Place to Work® Certified in Canada and the U.S.
Named as a “Top 10” employer by the Boston Globe’s “Top Places to Work” two years running

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

If you are a California resident, the salary range for this position is:

Southern region: $45,700 – 61,600 annually
Central region: $48,100 – 65,000 annually
Northern region: $51,500 – 69,400 annually

If you are a Colorado resident, the salary range for this position is $43,600 – 58,800 annually.

If you are a New York resident, the salary range for this position is $51,500 – 69,400 annually.

If you are Washington resident, the salary range for this position is $48,100 – 65,000 annually

We consider various factors in determining actual pay including your skills, qualifications, and experience.  In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.