You are as unique as your background, experience and point of view. Here, you'll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

JOB SUMMARY:

Serve as a resource and coach by providing support and answering questions to the various roles within C&G including: C&G Administrative Specialist, C&G Specialist I and C&G Specialist II. In addition, the position is responsible for the coordination of work management to ensure turnaround times are met while achieving superior operational performance and process excellence.

PRIMARY JOB RESPONSIBILITIES:

C&G Operations

• Run daily open case report and unassigned reports, monitor cases and communicate with staff to assist in prioritizing and assure compliance with case resolution timeframes. Approve case extensions upon request.
• Responsible for auditing cases and resolution letters for staff that is new, new to plan or if we are under a Corrective Action Plan. Lead needs to be fluent in all the types of cases within C&G with the ability to audit any plan and any type of case such as: provider appeal, member complaint/grievance, member appeal, Maximus packets, State Fair Hearing packets, etc
• Investigate and resolve legislative complaints, complaint appeals, escalated cases, etc
• Handle and resolve escalated calls
• Coordinating case corrections and ensuring corrections are completed timely and accurately
• Take ownership of escalated issues and ensure satisfactory resolution.
• Responds timely to requests sent to C&G Management regarding direction on case entry, etc.
• Assist in the on-going evaluation of policies and procedures, identify needs for new policies regarding internal
• Implementation and update of C& G system appeal and grievance templates.

Workflow management/team performance

• Provide leadership to the team and coordinate daily operations and workflow according to department guidelines and priorities.
• Provide support & 1-1 coaching during training phase for existing, and new staff members.
• Assist in ensuring staff meet or exceed productivity metrics. Acts as a coach and provides tips and suggestions as appropriate.
• Assist in mentoring, coaching and providing feedback to team members.
• Responsible for providing ongoing and development training to new and existing staff.

Provide support to department leadership

• Assist in meeting department & plan requirements by providing back up support to Specialists and performing team member functions as needed
• Acts as a liaison and obtains clarification from C&G Audits & Reporting or other areas when necessary to clarify a process that is unclear
• Update C&G management team on complaints and issues from clients, members, providers and internal staff. Is proactive in notifying C&G management if something is going to escalate.
• Facilitate resolution to internal and external issues.
• Attend client meeting or internal meetings as necessary to represent C&G. Present on departmental process and procedures to internal and external customers
• Acts as an extension of leadership and provides support for management decisions

Process Improvement

• Identify areas for improvement or processes that are unproductive, time consuming, and/or inefficient and communicate that information to management.
• Communicate ways to improve processes and procedures to management.

JOB QUALIFICATIONS:

Required Qualifications:

• High School Diploma or equivalent.
• Minimum 12 months of C&G experience with demonstrated success in C&G Specialist 1 or C&G Specialist II roles or higher-level roles such as Supervisor role.
• Proficient with general computer software including Microsoft Excel, Word and Outlook.
• Excellent verbal, written, interpersonal, organizational and communication skills.
• Ability to prioritize and organize multiple tasks with tight deadlines
• Proven ability to work well individually and with a team.
• Attention to detail, accuracy and organization skills is essential.
• Demonstrates self-motivation by taking initiative to learn more and take on more challenges.

Preferred Qualifications:

• Bachelor's degree in communications, social work, health care, or psychology.
• Experience working in a managed care environment.
• Previous leadership experience.

PHYSICAL DEMANDS:

• Ability to use basic office equipment and communicate via phone, computer technology, and via written and verbal channels.
• Ability to communicate in an active office environment, including moderate voice levels and interruptions, which may challenge hearing and concentration.
• Ability to sit for extended periods of time (approximately 75% of the time).

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 DentaQuest's Compliance Plan, employee must conduct DQ business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or DQ's Compliance Officer. **

DentaQuest's Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program.

Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email recruitingUS@sunlife.com to request an accommodation.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.