Job Description

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.

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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