Quality Management Coordinator

The Grievance Coordinator is an in-office position responsible for assisting with the preparation of dental records (charts and x-rays) opening new grievances and managing payer and dental board complaints. This position ensures all grievances and appeals are processed in a timely manner and that data is entered accurately. The QM Coordinator plays a key role in maintaining member satisfaction regulatory compliance and quality improvement initiatives.

• Receive document and acknowledge grievances and appeals within required timeframes.
• Investigate complaints involving dental benefits claims processing provider services and quality-of-care concerns including research and follow-up with dental offices.
• Prepare dental records including patient and office history dental ledgers and clinical documentation.
• Collaborate with internal teams including the Grievance Coordinator and Sr. Manager of QM to ensure proper handoff and resolution of grievances.
• Respond professionally and accurately using proper grammar to entities submitting complaints.
• Track and monitor open cases to ensure compliance with regulatory deadlines including state Department of Insurance CMS payer guidelines and NCQA standards.
• Maintain detailed and accurate documentation in the grievance tracking system and prepare 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 consistency and prevent recurrence of issues.
• Perform additional duties as needed to support the department.

Skills and Competencies

• Strong analytical and investigative skills with excellent 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 in Microsoft Office and Adobe Acrobat.
• Strong commitment to confidentiality professionalism and member advocacy

• Minimum of 1 year of experience in grievances appeals claims or customer service issue coordination preferably within dental or health insurance.
• Familiarity with dental terminology CDT codes and dental claims processing preferred.
• Must be willing to relocate or live in California for an in office role.