QM Coordinator
Western Dental & Orthodontics, Orange, CA, United States
The Grievance Coordinator is responsible for assisting with preparing dental records (charts and x-rays), opening new grievances, working with payer and dental board complaints. This position ensures that all grievances and appeals are processed timely and data entered accurately. The QM Coordinator plays a key role in maintaining member satisfaction, regulatory compliance, and quality improvement.
Responsibilities
Receive, document, and acknowledge grievances and appeals within required timeframes.
Investigate complaints, including research with dental offices, involving dental benefits, claims processing, provider services, and quality of care issues.
Prepare dental records, which include patient/office history and dental ledgers, and clinical documentation.
Collaborate with internal teams such as the Grievance Coordinator or Sr. Manager of QM to ensure proper hand-off of grievances for resolution.
Respond, where needed, accurately and with proper grammar to various entities submitting complaints.
Track and monitor open cases to ensure compliance with regulatory deadlines (e.g., state Department of Insurance, CMS, payer guidelines, and NCQA standards).
Maintain detailed and accurate documentation in the grievance tracking system and prepare regular reports on trends and outcomes, as requested.
Identify systemic issues or trends and recommend process improvements to enhance member, provider, and payer experiences.
Support audits, compliance reviews, and quality improvement initiatives as needed.
Educate teammates and others on grievance and appeals procedures to promote consistent handling and prevent recurrence of issues.
Perform other tasks as needed to support the department.
Skills and Competencies
Strong analytical and investigative skills, with attention to detail.
Excellent written and verbal communication skills.
Working knowledge of dental benefits administration, utilization review, and provider relations.
Ability to manage multiple priorities and meet strict deadlines.
Proficiency with Microsoft Office and Adobe.
Strong commitment to confidentiality, professionalism, and member advocacy.
Qualifications
1 year of experience in grievance or appeals or claims or customer services issue coordination, preferably in dental or health insurance.
Familiarity with dental terminology, CDT codes, and dental claims processing is preferred.
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Responsibilities
Receive, document, and acknowledge grievances and appeals within required timeframes.
Investigate complaints, including research with dental offices, involving dental benefits, claims processing, provider services, and quality of care issues.
Prepare dental records, which include patient/office history and dental ledgers, and clinical documentation.
Collaborate with internal teams such as the Grievance Coordinator or Sr. Manager of QM to ensure proper hand-off of grievances for resolution.
Respond, where needed, accurately and with proper grammar to various entities submitting complaints.
Track and monitor open cases to ensure compliance with regulatory deadlines (e.g., state Department of Insurance, CMS, payer guidelines, and NCQA standards).
Maintain detailed and accurate documentation in the grievance tracking system and prepare regular reports on trends and outcomes, as requested.
Identify systemic issues or trends and recommend process improvements to enhance member, provider, and payer experiences.
Support audits, compliance reviews, and quality improvement initiatives as needed.
Educate teammates and others on grievance and appeals procedures to promote consistent handling and prevent recurrence of issues.
Perform other tasks as needed to support the department.
Skills and Competencies
Strong analytical and investigative skills, with attention to detail.
Excellent written and verbal communication skills.
Working knowledge of dental benefits administration, utilization review, and provider relations.
Ability to manage multiple priorities and meet strict deadlines.
Proficiency with Microsoft Office and Adobe.
Strong commitment to confidentiality, professionalism, and member advocacy.
Qualifications
1 year of experience in grievance or appeals or claims or customer services issue coordination, preferably in dental or health insurance.
Familiarity with dental terminology, CDT codes, and dental claims processing is preferred.
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