Quality of Care Coordinator

Company: Delta Dental of California
Location: Alpharetta
Posted on: November 23, 2022

Job Description:

JOB DESCRIPTION

The Quality of Care Coordinator will be responsible for conducting critical analysis and responding to quality of care and service complaints and potential quality referrals for all lines of business. This position will oversee the complaint response process to facilitate timely resolutions and responses.

RESPONSIBILITIES

• Records all quality of care and quality of service complaints and potential quality referrals initiated by members and internal and/or external clinicians, and determines whether complaint is administrative or clinical in nature.
• Reviews clinical and dental records for completeness; reaches out to provider if record is incomplete and builds the case for review by the Dental Consultant.
• Performs research and identifies key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations that may apply to the complaint or referral.
• Summarizes cases, including articulation of complainant's perception, and presents essential information to Dental Consultant for review.
• Assigns reviews to clinical staff for quality of care inquiries requiring clinical review.
• Works with the Clinical Quality Specialists, Dental Consultants, and other clinical staff to ensure that clinical issues are addressed.
• Prepares case files for external review of complaints, including Independent Review Entity (IRE).
• Identifies the root causes of complaints and works with the applicable operational departments to implement an appropriate resolution.
• Communicates resolutions to the complainant via telephone or written correspondence.
  
  QUALIFICATIONS
  
  Minimum Qualifications
  
  • 1+ years of experience w/High School
  • Additional Experience
  • Experience in customer service, provider service, health service, or dental in a managed care or health care environment handling escalated or complex issues
  • Knowledge, Skills, Abilities
  • Proficient in using MS Office products - specifically using Excel to create pivot tables, and formulas
  • Excellent written and verbal communication skills
  • Strong detail orientation
  • Problem solving and critical thinking skills, with the ability to conduct research and identify steps required to resolve issues and follow through to completion
  • Passionate about changing the healthcare experience for our members
  • Energized by helping people and seeing the positive impact of your efforts
  • Resourceful and enjoy solving complicated problems to get to the root cause
  • Licenses
    
    ADDITIONAL INFORMATION
    
    Rewards to make you smile! We don't just want to make our customers happy - we want to give our employees a reason to smile, too. Delta Dental's comprehensive benefits package includes:
    
    
    • Generous paid time off plus 12 holidays and your birthday off!
    • Low-cost premium medical insurance options
    • 100% paid dental and vision insurance
    • Generous 401(k) matching and flat contribution
    • Social responsibility and volunteer opportunities, including 16 paid volunteer hours annually
    • Employee LiveWell program, focusing on overall employee well-being
    • Fertility and diabetes benefits
    • Employee discount program: AT&T/Verizon, entertainment, travel, and more!
    • Culture of learning: career development and tuition reimbursement
    • Career growth: we love promoting from within
      Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
      
      #LI-Hybrid
      
      ABOUT THE TEAM
      
      At Delta Dental, our success is only as strong as the people who execute it! We take enormous pride in being the nation's most recognized and widely-used provider of dental insurance - and we've come this far by living our core values of innovation, excellence, service and trust. Our vision is to motivate and empower every employee so that we're all inspired to take exceptional care of our customers, providers and ourselves. We believe in integrity, accountability, collaboration, and giving every employee equitable opportunity for their voice to be heard and development to be fostered.
      
      If you're excited about the prospect of transforming the future of health care and growing in your career, join our smile revolution!
      
      To see some of the smiling faces behind Delta Dental and to learn more about what our values and culture look like in action, connect with us on social media: Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn.
      
      We are part of the Delta Dental Plans Association, a network of companies that provides dental coverage to 74 million people in the U.S. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies, form one of the nation's largest dental benefits delivery systems, covering 33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country.
      
      Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
      
      Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico or other US Territories at this time.
      
      Proof of eligibility to work in the United States must be provided if selected for hire.
      
      Delta Dental* has enacted a COVID-19 vaccination policy to protect all employees and the communities we serve due to the ongoing impacts of the COVID-19 pandemic. Accordingly, we require all employees to be fully vaccinated for COVID-19. Are you able to comply with our policy of being fully vaccinated by your start date if an offer is made or have a medical or sincerely held religious exemption for receiving a COVID-19 vaccine? Failure to comply with our policy and submit proof of compliance or receive approval for a valid medical or sincerely held religious belief exemption prior to your start date will nullify any offer of employment extended to you.
      
      *Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York
      
      If You Are A Current Employee Click Here To Apply

Keywords: Delta Dental of California, Alpharetta , Quality of Care Coordinator, Other , Alpharetta, Georgia