We are seeking a highly detail-oriented and experienced Appeals Specialist to join our fully remote team. This vital role involves researching, processing, and resolving complex appeals and grievances related to dental benefit determinations, ensuring strict adherence to regulatory guidelines and established protocols. The ideal candidate will have specialized experience with managed care dental appeals processes, including those related to large-scale government and commercial dental benefit programs.
Location: 100% Remote (Must reside and be eligible to work in the US)
salary: $17.5 - $18 per hour
shift: First
work hours: 8 AM - 5 PM
education: High School
Responsibilities
Responsibilities:
- Manage a high-volume caseload of complex dental appeals, reconsiderations, and grievances initiated by members, providers, and regulatory bodies.
- Conduct thorough research into denied claims and adverse benefit determinations, utilizing dental policies, clinical criteria, plan documents, and regulatory requirements (including state-specific regulations for Medicaid and CHIP where applicable).
- Formulate clear, concise, and compliant written responses to appellants, explaining the determination and regulatory basis.
- Coordinate with internal clinical consultants and other departments to gather necessary documentation and clinical review information for case resolution.
- Minimum of 2-3 years of experience in a dedicated Appeals and Grievances role within a dental or medical insurance/managed care organization.
- Demonstrated, deep working knowledge of dental terminology (CDT codes), dental claims processing, and utilization management criteria.
- Proven expertise in handling appeals specific to managed dental care programs, including familiarity with processes and timeframes.
- Excellent written and verbal communication skills, with a proven ability to draft professional, regulatory-compliant correspondence.
Skills
Qualifications
Randstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad.
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.
Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).
This posting is open for thirty (30) days.
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
