Quality and Compliance Coordinator Dental

Responsibilities

• Receive, document, and acknowledge grievances and appeals within required timeframes.
• Investigate complaints involving dental benefits, claims processing, provider services, and quality-of-care concerns, including research and follow-up with dental offices.
• Prepare dental records, including patient and office history, dental ledgers, and clinical documentation.
• Collaborate with internal teams, including the Grievance Coordinator and Sr. Manager of QM, to ensure proper handoff and resolution of grievances.
• Respond professionally and accurately, using proper grammar, to entities submitting complaints.
• Track and monitor open cases to ensure compliance with regulatory deadlines, including state Department of Insurance, CMS, payer guidelines, and NCQA standards.
• Maintain detailed and accurate documentation in the grievance tracking system and prepare reports on trends and outcomes as requested.
• Identify systemic issues or trends and recommend process improvements to enhance member, provider, and payer experiences.
• Support audits, compliance reviews, and quality improvement initiatives as needed.
• Educate teammates and others on grievance and appeals procedures to promote consistency and prevent recurrence of issues.
• Perform additional duties as needed to support the department.

Qualifications

• Minimum of 1 year of experience in grievances, appeals, claims, or customer service issue coordination, preferably within dental or health insurance.
• Familiarity with dental terminology, CDT codes, and dental claims processing preferred.
• Must be willing to relocate or live in California for an in-office role.