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13 Feb 2020

Full-Time Complaints & Grievances Specialist II

RecruitDQ – Posted by RecruitDQ Milwaukee, Wisconsin, United States

Job Description


This position investigates and finds resolution of complaints, grievances and member appeals based upon specific regulatory requirements. In addition, the assembly and preparation of Maximus packets, State Fair Hearing packets as well as coordination and participation in State Fair Hearings. Daily interaction with assigned market/client contacts, as well as various internal departments. This position ensures all mandated turnaround times are met as well as required processes and workflows are adhered to.


  • Investigate and resolve complaints, grievances, and member appeals in accordance with State and/or Plan guidelines.
  • Investigate and resolve Level II and Level III requests (TennCare market only)
  • Comply with and resolve proof of compliance and directives Investigate and respond to SDOH (State Department of Health) and DOI (Department of Insurance) complaints
  • 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.
  • Investigate and respond to inquiries from the Better Business Bureau.
  • 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 our department tracking system, requests are acknowledged and resolved timely and accurately.
  • Expert in specific market nuances.
  • Proficiently trained to handle provider appeals and provides assistance to C&G Level I
  • Responds to follow ups daily Ability to identify and resolve issues that are unusual and not consistent with standard CGA workflows.
  • Represent the organization in a professional manner at all times.
  • Attend market meetings to represent C&G and share any new issues/changes that may be impactful to others in C&G.
  • Communicate to management ways to improve processes and productivity of company.
  • Establish and maintain professional relationships with Plan contacts.
  • Document all complaints in department tracking system.
  • Manage workflow to meet department, Plan, State, and company goals and deadlines.
  • Other duties as assigned.


  • High School Diploma or GED required.
  • 1 year of C&G experience with demonstrated success in C&G Specialist 1 or higher-level roles such as Lead or Supervisor role.
  • Typing skills of 40+ words per minute.
  • Excellent customer service skills.
  • Good PC Skills.
  • Excellent verbal and written communication skills.
  • PC experience with knowledge of Windows and the ability to work with other software applications is required.
  • Effective oral communication and business writing skills are required.
  • Attention to detail, accuracy and organizational skills are essential.
  • Effective interpersonal and organizational skills are essential.
  • Ability to prioritize and adapt to changing priorities is essential.
  • Resolve / investigate complaints in accordance with Plan guidelines.
  • Contact involved provider office to obtain information to properly review the case.
  • Document provider’s/staff’s perception of the member’s concerns / issues.
  • A follow-up letter is submitted to the Plan with the resolution/findings.
  • Assure health plans receive requested information as needed.
  • Establish and maintain professional relationships with Plan contacts.
  • Track complaints, grievances, and appeals in department tracking system
  • Adherence to department guidelines and timeframes.
  • Communicate ways to improve processes and procedures to management.
  • Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
  • Interacts in a cooperative, professional and effective manner with co-workers and DentaQuest staff.
  • Interacts in a cooperative, professional and effective manner with visitors, providers, and Plan representatives.
  • Ability to prioritize and organize multiple tasks.
  • Ability to remain organized with multiple interruptions.
  • Ability to work overtime as needed or required to meet business objectives.
  • Required to attend additional training as requested/deemed necessary.


  • Experience working in a managed care environment is desired.
  • College degree is desired.
  • Bachelor’s Degree in Communications, Social work, Health care, or Psychology preferred.

PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.

How to Apply

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Job Categories: Equal Opportunities. Job Types: Full-Time.

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