Appeals Specialist

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

The Appeal Specialist is responsible for the investigation and resolution of all administrative and clinical appeals based upon specific regulatory and or client requirements. In addition, this position is responsible for the assembly and preparation of responses to clients, members and/or providers. This position is responsible for daily interaction with assigned market/client contacts, as well as various internal departments. This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

The Appeal Specialist is responsible for the investigation and resolution of all administrative and clinical appeals based upon specific regulatory and or client requirements. In addition, this position is responsible for the assembly and preparation of responses to clients, members and/or providers. This position is responsible for daily interaction with assigned market/client contacts, as well as various internal departments. This position is also responsible to ensure that all mandated turnaround times are met as well as required processes and workflows are adhered to.

• Investigate, document and resolve member and provider appeals and inquiries related to appeals in accordance with State and/or Plan guidelines. Ensure all components of the appeal or request for information are researched and addressed.
• Assemble necessary information for the client so they may appropriately investigate an appeal when Denta Quest is secondary. If contracted to do so, also investigate the appeal and provide recommended outcome and appropriate correspondence.
• Monitor shared mailboxes and department e-mails to ensure cases are properly entered into department tracking system, and that requests are acknowledged and resolved timely and accurately.
• Manage workflow to meet department, Plan, State, and company goals and deadlines.
• Comply with and complete any client directives or overturns.
• Collaborate and partner with Complaint & Grievance team to resolve common issues oor trends.
• Take the lead in working with other internal departments/management team to ensure that any trends identified in appeals are communicated and rectified.
• Keep abreast of changes in market requirements and demonstrate expert knowledge in specific market nuances.
• Identify and resolve issues that are unusual and not consistent with standard workflows.
• Attend client or market meetings as assigned and share any new issues/changes that may be impactful.
• Establish and maintain professional relationships with Plan contacts.

• Contact involved provider office to obtain information to properly review the case. Document and summarize member's and provider's concerns / issues in a concise and easily readable format.
• Ensure all letter templates in use are correct and most recent versions are used.
• Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
• Other duties as assigned.

• High School Diploma or GED required.
• 1+ years experience in healthcare operations or…