We have an opportunity in the role of Complaints & Grievances Coordinator I, where under minimal guidance, drive continuous improvement and support the objectives of the Quality Management Department. This role will investigate and resolve complaints/grievances/appeals/provider disputes within specific State mandated time frames. They will continuously strive to provide superior products and customer service and proactively look at new and different ways of approaching work and share ideas and perspectives about increasing effectiveness and efficiency. The position requires the ability to effectively function in a team environment but also be a self-starter and work with minimal direction making independent decisions under pressure.
You will
Complaints & Grievances, Appeals & Provider Dispute Resolution
- Investigate and resolve complaints/grievances/appeals/provider disputes within specific State mandated time frames.
- As necessary, reconcile Regulatory and Executive Complaints per established policy/procedure and within state regulated timeframes and Coordinate resolution of Regulatory and Executive Complaints with compliance.
- Document accurate data in the appropriate database to ensure that members’ concerns are addressed and resolved including but not limited to attempts to obtain any/all information needed to definitively resolve the member’s concern.
- Ensure Resolution Letters are written in a clear and concise manner with an appropriate level of risk management and include any necessary State mandated enclosures.
- Keep files organized and readily accessible in FileNet.
System Documentation
- Identify and document accurate data in the QMP database and ensure the members’ concerns are appropriately addressed and resolved.
- Document notes in QMP in relation to steps taken and outreach made regarding the investigation of the Complaints/Grievances/Appeals/Provider Disputes. Notes are clear, concise and organized (chronologically).
- All documents relating to the investigation and resolution of a Complaint/Grievance and Appeal/Dispute are properly uploaded and labeled in FileNet in a timely manner.
Complaints & Grievances Intake Support
Provide support in the event of absence of the C&G Intake Coordinator, to ensure regulatory compliance by performing the following tasks included but not limited to:
- Monitor the Complaints & Grievances and Quality Management email inboxes and Quality Management Customer Care call database inboxes.
- Monitor the physical mail inbox for distribution.
- In a timely manner, identify and distribute follow-up requests to the appropriate internal Staff or Department
- Receive, identify and open Grievance requests for all Lines of Business and distribute the product specific Complaint Packets as necessary to members/patients as appropriate.
- Receive and prepare all incoming Complaint Packets.
- Compose Acknowledgement and Request for Records Letters for all Complaints/Grievances within State specific regulatory turnaround times.
- Prepare and upload all pertinent incoming Complaint/Grievance documentation to FileNet and update the QMP Database with the received date.
Special Projects
- Complete projects as assigned by the Complaints & Grievances Team Leader and/or Manager, Quality Management and Utilization Management within agreed upon timeframes.
- Assist with projects that drive continuous improvement and support the objectives of the Quality Management Program.
You have
- Minimum 2 years of Guardian dental plan and customer service experience mandatory.
- Preferred DHMO product experience.
- Strong Microsoft Word, Excel, PowerPoint skills.
- College degree preferred or a combination of education and relevant work experience. High School Diploma required.
- High level attention to detail.
- Strong knowledge of Guardian systems, state regulation and timeframes.
- Manages multiple tasks with multiple deliverables simultaneously.
- Excellent written and oral communication skills are mandatory.
Leadership Behaviors
- Continuously strives to provide superior/professional customer service.
- Expresses oneself in an open, honest and professional manner.
- Demonstrates self-awareness and embraces feedback.
Location
This is a remote position.
Salary Range
$39,370.00 – $59,050.00
The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation.
Our Promise
At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.
Inspire Well-Being
As part of Guardian’s Purpose – to inspire well-being – we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues.
Health Care
- Choice of [high deductible/copay] medical plans* with prescription drugs, including coverage for fertility and transgender inclusive benefits
- Dental plan
- Vision plan
- Health care accounts – flexible spending, health reimbursement, and health savings accounts
- Critical illness insurance
Life and Disability Insurance
- Company-paid Life and Disability insurance plus voluntary supplemental coverage
- Accident insurance
Retirement and Financial
- 401(k) retirement plan with a company match, plus an annual age/service-based Company contribution and an annual profit-sharing contribution, if applicable
- Complimentary 1:1 financial guidance with a licensed Fidelity representative
Time Off and Remote Work
- Flexible work arrangements (part in-person/part remote)
- Unlimited paid time off for most roles plus time off for volunteering, jury duty, voting, and bereavement
- Personal holidays for colleagues to use in recognition of religious, cultural, or civic days
- Paid parental leave and paid family and medical leave policies
Emotional Well-being and Work-Life
- Emotional well-being, mental health, and work/life resources powered by Spring Health
- Wellness programs, including fitness program and equipment reimbursement
- Child, adult, and elder back-up care support through Bright Horizons
- Adoption assistance
- College planning
- Tuition reimbursement
- Student loan assistance
- Commuter benefits in select metropolitan areas