Government Programs Appeals and Grievances Research Specialist

📋 Description

• • Serve as the critical link between Delta Dental’s 2.5 million government-program members and the high-quality oral-health outcomes they deserve. You will own the end-to-end lifecycle of appeals and grievances—translating complex dental terminology, state and federal regulations, and member concerns into clear, defensible resolutions that protect both the member and the integrity of the plan.
• • Dive deep into case files that span balance-billing disputes, allegations of non-delivery of care, quality-of-care complaints, personality conflicts, anti-fraud hotline tips, and internally escalated appeals. Your forensic mindset will guide you through contract review, CDT coding audits, provider billing scrutiny, and clinical record analysis to uncover root causes and craft evidence-based conclusions.
• • Build a narrative for every case. You will interview providers, members, and internal stakeholders; extract and synthesize data from claims platforms, document management systems, and regulatory databases; and translate your findings into concise, legally sound summaries stored in our case-management system for audit, compliance, and potential litigation support.
• • Act as a frontline defender against fraud, waste, and abuse. You will partner with our Special Investigations Unit to flag suspicious billing patterns, prepare referral packages, and occasionally testify in administrative hearings or depositions. Your work directly safeguards millions of dollars in taxpayer-funded benefits and reinforces public trust in Delta Dental’s government programs.
• • Own the technical adjudication of complex claims. When routine auto-adjudication hits a wall, you will manually price procedures, apply policy exceptions, post adjustments, and coordinate with Provider Relations to ensure accurate and timely payment—often under tight regulatory deadlines.
• • Champion continuous improvement. After each case cycle, you will analyze trends and recommend policy clarifications, training enhancements, or system configuration changes that prevent repeat issues and elevate the member experience.
• • Collaborate in a fully remote yet highly connected environment. Daily huddles, Microsoft Teams brainstorming sessions, and quarterly in-person summits in Okemos, MI keep the team aligned, energized, and focused on our All In culture.
• • Present findings to diverse audiences—ranging from concerned members seeking plain-language explanations to attorneys requiring technical exhibits—always balancing empathy, accuracy, and compliance.
• • Maintain meticulous documentation that withstands CMS, state Medicaid, and external auditor scrutiny. Your case files will serve as the single source of truth for regulatory reporting, performance dashboards, and executive briefings.
• • Contribute to enterprise-wide initiatives such as annual compliance audits, new-product rollouts for dual-eligible populations, and cross-functional task forces exploring AI-driven fraud detection—leveraging your on-the-ground expertise to shape the next generation of dental benefits administration.