The Grievance Coordinator is responsible for assisting with preparing dental records (charts and x-rays), opening new grievances, working with payer and dental board complaints. This position ensures that all grievances and appeals are processed timely and data entered accurately. The QM Coordinator plays a key role in maintaining member satisfaction, regulatory compliance, and quality improvement. 

• Receive, document, and acknowledge grievances and appeals within required timeframes. 

• Investigate complaints, including research with dental offices, involving dental benefits, claims processing, provider services, and quality of care issues. 

• Prepare dental records, which include patient/office history and dental ledgers, and clinical documentation. 

• Collaborate with internal teams such as the Grievance Coordinator or Sr. Manager of QM to ensure proper hand-off of grievances for resolution. 

• Respond, where needed, accurately and with proper grammar to various entities submitting complaints. 

• Track and monitor open cases to ensure compliance with regulatory deadlines (e.g., state Department of Insurance, CMS, payer guidelines, and NCQA standards). 

• Maintain detailed and accurate documentation in the grievance tracking system and prepare regular 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 consistent handling and prevent recurrence of issues. 

• Perform other tasks as needed to support the department. 

Skills and Competencies: 

• Strong analytical and investigative skills, with attention to detail. 

• Excellent written and verbal communication skills. 

• Working knowledge of dental benefits administration, utilization review, and provider relations. 

• Ability to manage multiple priorities and meet strict deadlines. 

• Proficiency with Microsoft Office and Adobe. 

• Strong commitment to confidentiality, professionalism, and member advocacy. 

• 1 year of experience in grievance or appeals or claims or customer services issue coordination, preferably in dental or health insurance. 

• Familiarity with dental terminology, CDT codes, and dental claims processing is preferred.