Delta Dental of Arkansas

Analyst

• Research incoming appeals, grievances and complaints, including consideration and reconsideration requests, to properly identify and categorize as processed claims (grievances), denied services (appeals or self-funded (ASO) group requests) or complaints
• Collect all appropriate data and information, and process for clinical or contract consideration as appropriate.
• Coordinate case review with dental consultants.
• Coordinate timely handling and resolution responses for high volume of appeals and grievances within various regulatory and contractual timelines
• Reconcile across systems to ensure that all member appeals and grievance are logged and tracked.
• Direct external independent reviews to the appropriate independent review organization (IRO)
• Document records in accordance with DOI guidance requirements
• Prepare and manage all monthly and quarterly customer and internal reporting
• Communicate effectively with other departments such as Claims and Customer Service, Billing & Eligibility, Marketing and Professional Relations to ensure complete and fair reviews of complaints, grievances and appeals

Appeals and Grievances Analyst