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Must be within a commutable distance of the Oriskany, NY, office location

In office once a month for meetings

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Key Responsibilities:

Investigation & Resolution

* Conduct thorough investigations of complaints and grievances, including issues such as Quality of Care, Coverage Disputes, Access to Care, and State Complaints.

* Review and identify complaint issues in conjunction with insurance plan provisions and applicable regulations.

* Determine corrective actions and resolution decisions, including claim reprocessing and provider/member reimbursement when applicable.

Communication & Documentation

* Prepare comprehensive written responses addressing all concerns and corrective actions taken.

* Respond to telephonic inquiries from members and providers regarding complaint outcomes.

Collaboration

* Collaborate with internal partner areas such as Claims Operations, Legal, Compliance, Network Development, and SIU.

* Refer cases to Legal, Litigation, or SIU departments when necessary.

Compliance & Reporting

* Ensure all decisions and correspondence comply with plan contracts and state regulations.

* Maintain accurate and thorough complaint statistics for reporting and trending purposes.

* Monitor deadlines to meet time service standards and regulatory requirements.

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Required Qualifications:

* Knowledge of claims process

* High School Diploma or equivalent.

* Strong verbal and written communication skills.

* Proven customer service and conflict resolution abilities.

* Analytical skills for interpreting, evaluating claims, and analyzing reports & data.

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Preferred Qualifications:

* Minimum 5 years of experience in Dental.

* Knowledge of Dental terminology, procedures, and group plan contracts.

* Familiarity with systems such as NOVA, Dental SIR, MetCor, Insight platforms.

* Experience with MS Office (Excel, Powerpoint, CoPilot) a plus.

* Advanced knowledge of dental processes, procedure codes, and clinical terminology.

* Experience handling regulatory complaints.

* Ability to build relationships across departments and with external stakeholders.

* Sound business judgment and decision-making skills.

Equal Employment Opportunity/Disability/Veterans

If you need an accommodation due to a disability, please email us at [email protected]. This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

MetLife maintains a drug-free workplace.