DentaQuest
Complaints & Grievances Specialist II, DentaQuest
DentaQuest, Milwaukee, Wisconsin, United States, 53244
Join the Complaints & Grievances Specialist II role at DentaQuest. This position handles the investigation and resolution of complaints, grievances, and member appeals, ensuring compliance with regulatory requirements and turnaround goals.
Location Sun Life embraces a hybrid work model that balances in‑office collaboration 2 days per week with flexible virtual work. Our team members and leaders are expected to be present in the office at least 2 days per week.
The Opportunity The Complaints & Grievances Specialist II handles the investigation and resolution of complaints, grievances, and member appeals based upon specific regulatory requirements. Responsibilities include assembly and preparation of Maximus packets, State Fair Hearing packets, coordination and participation in State Fair Hearings, daily interaction with assigned market/client contacts, and ensuring all mandated turnaround times are met.
How You Will Contribute
Investigate and resolve complaints and grievances in accordance with State and/or Plan guidelines.
Handle member complaints, plan‑submitted complaints, provider complaints, SDOH complaints, DOI complaints, BBB complaints, executive complaints, and other formal grievance process submissions.
Prepare State Fair Hearing packets and coordinate scheduling of hearings.
Assemble information for the plan to investigate member appeals/complaints when not delegated.
Monitor shared mailboxes and department e‑mails to ensure cases are entered into the tracking system and requests are acknowledged and resolved timely.
Manage workflow to meet department, plan, State, and company goals and deadlines.
Comply with and resolve proof of compliance and directives.
Contact involved provider offices to obtain information and document provider or staff perception of the member’s concerns.
Document all complaints, grievances, and appeals in the department tracking system.
What You Will Bring
High School Diploma or GED required.
1 year of complaints & grievance experience with demonstrated success, or 2 years in claims, customer service, provider network, or another operational function.
Proficiency with general computer software including Microsoft Excel, Word and Outlook.
Excellent verbal, written, interpersonal, organizational, and communication skills.
Excellent research skills with ability to identify underlying issues not articulated.
Ability to remain calm and focused in a high‑pressure, high‑workload environment.
Ability to work in a high‑stress environment and prioritize and organize multiple tasks with tight deadlines.
Ability to remain organized with multiple interruptions.
Willingness to work overtime as needed to meet business objectives.
Salary $49,200 – $66,400 annually. Eligible for a discretionary annual incentive award.
Benefits & EEO Sun Life prioritizes well‑being with comprehensive benefits: generous vacation and sick time, paid family, parental and adoption leave, medical coverage, company‑paid life and AD&D insurance, disability programs, a partially paid sabbatical, 401(k) employer match, stock purchase options, and an employer‑funded retirement account. We foster an inclusive environment where all employees feel they belong, are supported, and empowered to thrive. Sun Life will consider all qualified applicants, including those with criminal histories, in accordance with applicable state and local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We will make reasonable accommodations for qualified individuals with disabilities or special disabled veterans unless it would impose an undue hardship on business operations.
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Location Sun Life embraces a hybrid work model that balances in‑office collaboration 2 days per week with flexible virtual work. Our team members and leaders are expected to be present in the office at least 2 days per week.
The Opportunity The Complaints & Grievances Specialist II handles the investigation and resolution of complaints, grievances, and member appeals based upon specific regulatory requirements. Responsibilities include assembly and preparation of Maximus packets, State Fair Hearing packets, coordination and participation in State Fair Hearings, daily interaction with assigned market/client contacts, and ensuring all mandated turnaround times are met.
How You Will Contribute
Investigate and resolve complaints and grievances in accordance with State and/or Plan guidelines.
Handle member complaints, plan‑submitted complaints, provider complaints, SDOH complaints, DOI complaints, BBB complaints, executive complaints, and other formal grievance process submissions.
Prepare State Fair Hearing packets and coordinate scheduling of hearings.
Assemble information for the plan to investigate member appeals/complaints when not delegated.
Monitor shared mailboxes and department e‑mails to ensure cases are entered into the tracking system and requests are acknowledged and resolved timely.
Manage workflow to meet department, plan, State, and company goals and deadlines.
Comply with and resolve proof of compliance and directives.
Contact involved provider offices to obtain information and document provider or staff perception of the member’s concerns.
Document all complaints, grievances, and appeals in the department tracking system.
What You Will Bring
High School Diploma or GED required.
1 year of complaints & grievance experience with demonstrated success, or 2 years in claims, customer service, provider network, or another operational function.
Proficiency with general computer software including Microsoft Excel, Word and Outlook.
Excellent verbal, written, interpersonal, organizational, and communication skills.
Excellent research skills with ability to identify underlying issues not articulated.
Ability to remain calm and focused in a high‑pressure, high‑workload environment.
Ability to work in a high‑stress environment and prioritize and organize multiple tasks with tight deadlines.
Ability to remain organized with multiple interruptions.
Willingness to work overtime as needed to meet business objectives.
Salary $49,200 – $66,400 annually. Eligible for a discretionary annual incentive award.
Benefits & EEO Sun Life prioritizes well‑being with comprehensive benefits: generous vacation and sick time, paid family, parental and adoption leave, medical coverage, company‑paid life and AD&D insurance, disability programs, a partially paid sabbatical, 401(k) employer match, stock purchase options, and an employer‑funded retirement account. We foster an inclusive environment where all employees feel they belong, are supported, and empowered to thrive. Sun Life will consider all qualified applicants, including those with criminal histories, in accordance with applicable state and local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We will make reasonable accommodations for qualified individuals with disabilities or special disabled veterans unless it would impose an undue hardship on business operations.
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