Position Summary

The Appeals & Grievances Coordinator is responsible for the accurate and timely processing of appeals and grievances in compliance with regulatory requirements and organizational policies. This role plays a critical part in ensuring member satisfaction, regulatory compliance, and fair resolution of disputes related to benefits, claims, and services.

Job Responsibilities

• Receive, review, and process appeals and grievances in accordance with state, federal, and organizational guidelines
• Conduct thorough investigations by reviewing records, claims data, benefit plans, and correspondence
• Coordinate with internal departments (Claims, Provider Relations, Customer Service) to gather necessary information
• Prepare clear, accurate, and compliant written determinations within required turnaround times
• Track and document appeal and grievance activities in designated systems
• Identify trends, issues, or recurring concerns and escalate as appropriate

Required Qualifications

• Associate degree in Healthcare, Business, or a related field (or equivalent experience)

• 1–3 years of experience in healthcare appeals and grievances, claims, medical management, or a related healthcare operations role
• Strong customer service skills and customer service focus
• Strong written and verbal communication skills
• Excellent attention to detail and organizational skills
• Ability to manage complex cases and meet strict deadlines

Preferred Qualifications

• Experience in dental care or dental insurance industry
• Prior experience drafting appeal and grievance determination letters
• Experience with appeals and grievances tracking systems or case management software
• Prior experience working in a remote environment

PHYSICAL DEMANDS:

• Incumbent must be able to communicate effectively.
• Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer).
• Ability to travel or move about within and outside serviced facilities required.
• Incumbent works primarily in either a private or shared office environment.

The target hiring range for this role is $53,380 - $72,220 ( Annually). The starting base salary will be determined based on skills, experience, and other job-related factors. In addition, our total rewards package includes medical, dental, and vision plans; generous time off including PTO, short and long-term disability insurance and a competitive 401(k) savings match including financial planning workshops. See our Careers Page for more information.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.

** In accordance with Delta Dental of Massachusetts’ Compliance Plan, all employees must conduct Delta Dental of Massachusetts business and activities in accordance with applicable laws, regulations, professional standards, and ethical standards and report potential compliance or ethical issues to Delta Dental of Massachusetts’ designated Compliance Officer. **

Delta Dental of Massachusetts’ Affirmative Action Program affirms our commitment to make reasonable accommodations for 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 and activities. Please see Human Resources for additional information regarding this program.