Medicare and Medicaid Complaint Coordinator

Title: Medicare and Medicaid Complaint Coordinator - Hybrid Alpharetta

Location: Rancho Cordova United States

Job Description:

The Medicare and Medicaid Complaint Coordinator is responsible for managing and responding to complaints initiated by Medicare Advantage Organizations (MAOs) and Medicaid carriers, ensuring a streamlined and timely resolution process. This role involves direct communication with MAOs, internal business partners, and providers, as well as participation in meetings with plans, Account Managers, and cross-functional teams to address concerns effectively.

Please note this position is hybrid and requires the employee to report to the Alpharetta office as needed for meaningful in-person events such as town halls, team building, training, volunteering, etc.

• Log, track, and manage inquiries, appeals, and grievances from MAOs and Medicaid carriers.
• Investigate complaints by collaborating with MAO plans, providers, and internal departments, ensuring thorough information gathering and resolution.
• Conduct research to identify relevant policies, including plan provisions, Evidence of Coverage (EOC), and regulatory guidelines applicable to appeals and grievances.
• Request, obtain, and document detailed invoices as necessary to support research and case resolution.
• Summarize case details and compile necessary clinical documentation for review by the Clinical Review department, working closely with Dental Consultants and clinical staff to address medical or dental-related concerns.
• Ensure all appeals comply with State, Federal, and Delta Dental quality guidelines, meeting required timelines and resolution standards.
• Assist in coordinating interdepartmental issue resolution efficiently and effectively.
• Ability to work a starting schedule of 8 a.m. to 4:45 p.m. eastern, Monday through Friday. Alternative schedule options may be considered after the training/nesting period based on performance.
• Experience in customer service, provider services, healthcare, or dental managed care, handling complex or escalated issues in government and commercial insurance.
• 3 or more years' experience researching and resolving inquiries from State and Federal agencies regarding Medicare and Medicaid complaints.
• Strong problem-solving and critical-thinking skills, with the ability to analyze cases, identify solutions, and drive them to resolution.
• Excellent organizational and time management abilities, with keen attention to detail.
• Basic proficiency in Microsoft Office.
• Strong verbal and written communication skills, with the ability to engage and collaborate with diverse stakeholders.
• Excellent ability to thrive in a fast-paced, high-production environment.

Base Pay Information

The national base pay range at the end is a good faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications, and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.

Pay Grade 15. $40,500 - $84,800