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.
*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.
Equal Employment Opportunity/Disability/Veterans
If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process.
MetLife maintains a drug-free workplace.
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