Quality Management Coordinator

The Grievance Coordinator is responsible forassisting with preparing dental records (charts andx-rays) opening new grievancesworking with payer and dental board complaints.This position ensures that all grievances and appeals areprocessed timelyanddata enteredaccurately. TheQMCoordinator 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 officesinvolving dental benefits claims processing provider services and quality of care issues.

• Prepare dentalrecords which include patient/office history anddentalledgersandclinical documentation.

• Collaborate with internal teams such asthe 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 CMSpayer guidelines andNCQA 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 memberprovider and payerexperiences.

• Support audits compliance reviews and quality improvement initiatives as needed.

• Educateteammatesandotherson 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 Officeand Adobe.

• Strong commitment to confidentiality professionalism and member advocacy.

• 1year of experience in grievance or appealsor claims or customer services issuecoordination preferably in dental or health insurance.

• Familiarity with dental terminology CDT codes and dental claims processingispreferred.