Government Programs Appeals and Grievances Compliance Specialist

Job Summary: Job Title:

Government Programs Appeals and Grievances Compliance Specialist

Number of Positions:

1

Location:

Okemos, MI

Location Specifics:

Hybrid Position

Job Summary:

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description:

Provides compliance oversight and operational guidance to management and staff responsible for resolving member appeals and grievances, including monitoring adherence to regulatory, contractual, and internal policy requirements, supports internally identified claim recoupments, provider billing issues, and client referrals, and contributes to the fraud and abuse program activities through documentation, reporting, and audit readiness.

Primary Job Responsibilities:

• Develops, maintains, and delivers training materials and job aids; provides refresher training to reinforce regulatory, contractual, and policy requirements; and trains and supports new employees to ensure consistent, compliant application of appeals and grievances procedures.
• Conducts comprehensive monthly quality and compliance audits of appeals and grievances to validate timeliness, accuracy, completeness, and adherence to regulatory, contractual, and internal requirements; documents findings, identifies root causes, and tracks corrective and preventive actions.
• Develops and maintains departmental procedures, controls, and reference materials to ensure processes remain current and compliant with company standards, contractual obligations, and applicable regulations.
• Develops and maintains a controlled document repository of member and provider documents to support audit readiness, including ensuring consistency with company standards, contractual requirements, and applicable retention and confidentiality requirements.
• Supports internal and external audits by coordinating requests, compiling audit samples and supporting evidence, responding to audit questions, and assisting with remediation activities and documentation of corrective actions.
• Serves as a compliance and process subject matter expert for the Government Programs Appeals and Grievances team during internal and external audits and meetings by explaining departmental workflows, controls, documentation standards, and key compliance requirements.
• Assists in assigning work and performing appeal and grievance reviews to help meet departmental deadlines, as needed.
• Provides day-to-day compliance support to the appeals and grievances team by answering process and policy questions, performing research, interpreting applicable requirements, and escalating potential compliance risks or issues as appropriate.
  
  

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Minimum Requirements:

Position requires a bachelor’s degree in accounting, business administration, criminal justice, health care administration, dental assisting or hygiene, or a related field and three years of resolving complaints in the dental insurance industry or six years of experience in a position requiring knowledge of dental office billing and record keeping practices within a provider office, administering benefit contracts within the insurance industry, or identifying, analyzing, and resolving compliance issues based on policies and procedures outside of the insurance industry. Previous experience supporting an anti-fraud/abuse program and/or audit/compliance monitoring activities preferred. Will accept any suitable combination of education, training, or experience.

Position also requires knowledge of word processing, spreadsheet, and database applications; strong verbal and written communication skills; strong analytical skills; the ability to work independently and as part of a team; the ability to manage multiple assignments with competing deadlines; and the ability to identify and resolve problems using independent judgment.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.