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Network Grievance Advocate

Date Posted: Mar 12, 2019

Location: Irvine, CA, US, 92614

Company: MetLife

Job Location: United States : California : Irvine  

 

Role Value Proposition: 

The Network Grievance Advocate provides quality assurance for the Dental and Vision Grievance Unit, assists in the responsibilities for the overall support of the unit, and researches and resolves all grievances/appeal issues raised by the member/provider by using multiple platform electronic database files. The person in this role researches and analyzes information and handles discrepancies and also develops and presents results and recommendations with internal departments to resolve grievances/appeals. Additionally, this person creates and maintains a positive working relationship with both internal and external customers and responds to telephone and written inquiries from external and internal customers. 

 

Key Responsibilities:  

  • Acts as the primary contact for all parties involved in dental grievance issues. 
  • Provides personalized service for complex/escalated grievance issues to varied customers in a professional, timely manner; conducts root cause analyses when needed. 
  • Recognizes potential fraud issues and refers to applicable point of contact. 
  • Analyzes and prepares detailed responses by written correspondence, faxes, or by phone regarding grievance issues with specific time constraints ensuring that performance guarantees are achieved. 
  • Processes grievances, identifies trends that need improvements (i.e. system enhancements, training needs, quality, etc.), and works to improve the end-to-end process within Claims, Call Center, Provider Relations and the Accounts Team. 
  • Recommends and implements appropriate process improvement opportunities. 
  • Proactively consults with management and the Provider Relations Unit regarding customer concerns. 
  • Collects and records revenue received or paid out through the balance-billing department and claims overpayment department.
  • Coordinates and participates in committee peer review group meetings for possible termination of dentist. 
  • Provides directional guidance and policy interpretation to external/internal members. 
  • Assists with questions and problems within the network to external/internal staff and members. 
  • Creates and maintains a positive working relationship with both internal and external customers. . 
  • Processes credit checks returned relating to balance billing refunds due.
  • Assists with special projects as needed.
  • Performs other related duties as assigned or required.

 

Essential Business Experience and Technical Skills:

Required:

  • High school diploma or GED.
  • 5+ yrs. of  either dental grievance background, dental office background or customer service background for an HMO dental insurance company.

 

Preferred:

  • Dental Claim Insurance experience preferred.

 

At MetLife, we’re leading the global transformation of an industry we’ve long defined. United in purpose, diverse in perspective, we’re dedicated to making a difference in the lives of our customers.” 

 



 

 

 

MetLife is a proud equal opportunity/affirmative action employer committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. It is MetLife's policy to ensure equal employment opportunity without discrimination or harassment based on race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

MetLife maintains a drug-free workplace.

For immediate consideration, click the Apply Now button. You will be directed to complete an on-line profile. Upon completion, you will receive an automated confirmation email verifying you have successfully applied to the job.

Requisition #: 107440 


Nearest Major Market: Irvine California
Nearest Secondary Market: Los Angeles