Complaints & Litigation Specialist Job at MetLife, Oriskany, NY

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  • MetLife
  • Oriskany, NY

Job Description

Must be within a commutable distance of the Oriskany, NY, office location

In office once a month for meetings

Key Responsibilities:

Investigation & Resolution

  • Conduct thorough investigations of complaints and grievances, including issues such as Quality of Care, Coverage Disputes, Access to Care, and State Complaints.

  • Review and identify complaint issues in conjunction with insurance plan provisions and applicable regulations.

  • Determine corrective actions and resolution decisions, including claim reprocessing and provider/member reimbursement when applicable.

Communication & Documentation

  • Prepare comprehensive written responses addressing all concerns and corrective actions taken.

  • Respond to telephonic inquiries from members and providers regarding complaint outcomes.

Collaboration

  • Collaborate with internal partner areas such as Claims Operations, Legal, Compliance, Network Development, and SIU.

  • Refer cases to Legal, Litigation, or SIU departments when necessary.

Compliance & Reporting

  • Ensure all decisions and correspondence comply with plan contracts and state regulations.

  • Maintain accurate and thorough complaint statistics for reporting and trending purposes.

  • Monitor deadlines to meet time service standards and regulatory requirements.

Required Qualifications:

  • Knowledge of claims process

  • High School Diploma or equivalent.

  • Strong verbal and written communication skills.

  • Proven customer service and conflict resolution abilities.

  • Analytical skills for interpreting, evaluating claims, and analyzing reports & data.

    *

Preferred Qualifications:

  • Minimum 5 years of experience in Dental.

  • Knowledge of Dental terminology, procedures, and group plan contracts.

  • Familiarity with systems such as NOVA, Dental SIR, MetCor, Insight platforms.

  • Experience with MS Office (Excel, Powerpoint, CoPilot) a plus.

  • Advanced knowledge of dental processes, procedure codes, and clinical terminology.

  • Experience handling regulatory complaints.

  • Ability to build relationships across departments and with external stakeholders.

  • Sound business judgment and decision-making skills.

Equal Employment Opportunity/Disability/Veterans

If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

MetLife maintains a drug-free workplace.

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