Customer Support

• Investigate, document and resolve member and provider appeals and inquiries related to appeals in accordance with State and/or Plan guidelines
• Ensure all components of the appeal or request for information are researched and addressed
• Assemble necessary information for the client so they may appropriately investigate an appeal when DentaQuest is secondary
• If contracted to do so, also investigate the appeal and provide recommended outcome and appropriate correspondence
• Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately
• Manage workflow to meet department, Plan, State, and company goals and deadlines
• Comply with and complete any client directives or overturns
• Collaborate and partner with Complaint & Grievance team to resolve common issues or trends
• Take the lead in working with other internal departments/management team to ensure that any trends identified in appeals are communicated and rectified
• Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances
• Identify and resolve issues that are unusual and not consistent with standard workflows
• Attend client or market meetings as assigned and share any new issues/changes that may be impactful
• Establish and maintain professional relationships with Plan contacts
• Contact involved provider office to obtain information to properly review the case
• Document and summarize member’s and provider’s concerns / issues in a concise and easily readable format
• Ensure all letter templates in use are correct and most recent versions are used
• Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management
• Other duties as assigned

Appeals Support Specialist

Customer Service Manager

Customer Service Representative