MetLife

Must be within a commutable distance of the Oriskany, NY, office location

In office once a month for meetings

Key Responsibilities:

Investigation & Resolution

• Conduct thorough investigations of complaints and grievances, including issues such as Quality of Care, Coverage Disputes, Access to Care, and State Complaints. 
• Review and identify complaint issues in conjunction with insurance plan provisions and applicable regulations. 
• Determine corrective actions and resolution decisions, including claim reprocessing and provider/member reimbursement when applicable.

Communication & Documentation

• Prepare comprehensive written responses addressing all concerns and corrective actions taken. 
• Respond to telephonic inquiries from members and providers regarding complaint outcomes. 

Collaboration

• Collaborate with internal partner areas such as Claims Operations, Legal, Compliance, Network Development, and SIU. 
• Refer cases to Legal, Litigation, or SIU departments when necessary. 

Compliance & Reporting

• Ensure all decisions and correspondence comply with plan contracts and state regulations. 
• Maintain accurate and thorough complaint statistics for reporting and trending purposes. 
• Monitor deadlines to meet time service standards and regulatory requirements. 

Required Qualifications:

• Knowledge of claims process 
• High School Diploma or equivalent.
• Strong verbal and written communication skills.
• Proven customer service and conflict resolution abilities.
• Analytical skills for interpreting, evaluating claims, and analyzing reports & data.
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Preferred Qualifications:

• Minimum 5 years of experience in Dental. 
• Knowledge of Dental terminology, procedures, and group plan contracts.

• Familiarity with systems such as NOVA, Dental SIR, MetCor, Insight platforms. 
• Experience with MS Office (Excel, Powerpoint, CoPilot) a plus.
• Advanced knowledge of dental processes, procedure codes, and clinical terminology.
• Experience handling regulatory complaints.
• Ability to build relationships across departments and with external stakeholders.
• Sound business judgment and decision-making skills.