• Conduct research to identify relevant clinical guidelines, plan policies, regulatory requirements, and applicable rules (DMHC/DHCS, EOC).
• Summarize cases, articulate complainant concerns, and present findings to the Dental Consultant for further evaluation.
• Assign clinical reviews for inquiries involving quality of care issues.
• Collaborate with Clinical Quality Specialists, Dental Consultants, and other staff to ensure clinical issues are effectively resolved.
• Prepare comprehensive case files for external reviews, including Independent Review Entity (IRE) submissions.
• Investigate root causes of complaints and coordinate with operational teams to implement appropriate resolutions.
• Communicate resolutions to complainants professionally via phone or written correspondence.
Qualifications:

• Ability to work a starting schedule of Monday through Friday, 8:00 a.m. to 4:45 p.m. and report to the office on an as needed basis.
• Minimum of 1 year of relevant experience with a high school diploma/GED.
• Background in customer service, provider service, health services, or dental roles within managed care or healthcare environments, including handling escalated or complex issues.
• Proficient in MS Office Suite, with expertise in Excel (e.g., pivot tables, formulas).
• Experience reading an appeals ledger is a plus!
• Strong written and verbal communication skills.
• High attention to detail and organizational skills.
• Proven problem-solving and critical thinking abilities to research and resolve complex issues.
• Passionate about enhancing the healthcare experience for members.
• Motivated by helping others and seeing the positive impact of your work.
• Resourceful, analytical, and adept at identifying root causes to resolve problems effectively.

Base Pay Information

The national base pay range is a good faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications, and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. Pay Grade 16. $40,500 - $84,800

Additional Information:

Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:

• Competitive base and incentive pay
• 401(k) with robust matching and non-matching contributions
• Rich medical & pharmacy benefits
• 100% employer-paid dental and vision benefits
• Holistic wellbeing program with deep financial incentives
• Generous paid time off plus 12 paid holidays and your birthday off
• Culture of growth and learning: career development; tuition reimbursement; recognition program
• Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
• Social responsibility and volunteer opportunities
• Employee discount program

Fair Chance Ordinances and Criminal Background Considerations

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all applicable federal, state, and local laws, including, but not limited to, fair chance and anti-discrimination ordinances. At Delta Dental, we maintain a strict stance on theft, fraud, and violent crimes. For positions involving driving, we enforce heightened standards regarding driving records. Each individual criminal background check is evaluated on its merits, taking into account the time elapsed since the conviction, evidence of personal development and rehabilitation, and any potential risk posed to our business operations, employees, customers, or vendors.

Important Work Authorization Information

Please note, Delta Dental will not sponsor applicants for work visas for this position.

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