Complaints & Grievances Specialist II, DentaQuest

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.  

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work.

The opportunity:  

The Complaints & Grievances Specialist II is responsible for the investigation and resolution of complaints, grievances and member appeals based upon specific regulatory requirements.  In addition, responsible for the assembly and preparation of Maximus packets, State Fair Hearing packets as well as coordination and participation in State Fair Hearings.  Responsible for daily interaction with assigned market/client contacts, as well as various internal departments.  This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

How you will contribute:  

Investigate and resolve complaints and grievances in accordance with State and/or Plan guidelines. Ensure all components of the grievance/complaint are researched and addressed.  Complaints/grievances that this role is responsible for include:

• Member Complaints/Grievances

• Member Complaints/Grievances submitted by plan (when DQ is secondary)

• Provider Complaint

• SDOH (State Department of Health) complaints

• DOI (Department of Insurance) complaints

• BBB (Better Business Bureau) complaints

• Executive complaints (complaints addressed to executives of DentaQuest)

• Any other complaints/grievance submitted as part of the formal grievance process

• Prepare State Fair Hearing packets and coordinate scheduling State Fair Hearing reviews

• Assemble necessary information for the plan so they may appropriately investigate member appeals/complaints when we are not delegated.

• Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately.  Manage workflow to meet department, Plan, State, and company goals and deadlines.

• Comply with and resolve proof of compliance and directives.

• Contact involved provider office to obtain information to properly review the case. Document  provider's/staff's perception of the member's concerns / issues. 

• Document all complaints/grievances/appeals in department tracking system.

• Other duties as assigned.

 What you will bring with you:  

• High School Diploma or GED required.

• 1 year of C&G experience with demonstrated success in C&G Specialist I or 2 years' experience in claims, customer service, provider network or another operational function.

• Proficient with general computer software including Microsoft Excel, Word and Outlook.

• Excellent verbal, written, interpersonal, organizational and communication skills.

• Excellent research skills with ability to identify underlying issue(s) not articulated

• Ability to remain calm and focused in a high pressure/high workload environment

• Ability to work in a high stress environment.

• Ability to prioritize and organize multiple tasks with tight deadlines.

• Ability to remain organized with multiple interruptions.

• Ability to work overtime as needed or required to meet business objectives.

Salary:  

Salary Range: $47,100 - $63,600
At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

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We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive.  We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate.  We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program.  Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account.  Enjoy a flexible, inclusive and collaborative work environment that supports career growth.  We’re proud to be recognized in our communities as a top employer.  Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.  Visit our website to learn more about our benefits and recognition within our communities.

We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [email protected] to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.