The Operations Document Specialist III is responsible for identifying changes to State and/or Federal regulations, MCO contracts or NCQA requirements that may affect content of letters generated from Utilization Management and Complaints and Grievances activity. In addition participate in Market Meetings to understand Client requirements and communicate any items that will impact determination or appeal letters; maintain tracking mechanism for current and historical templates for each client; and to perform periodic audit of templates in production to ensure most recent approved version is being used. The Operations Document Specialist III will also coordinate with Client Services and/or Correspondence Systems to make any necessary changes. It may also be necessary to coordinate efforts with internal staff to resolve issues. All Operations Document Specialists are expected to meet the guidelines and turnaround times relating to determination letters set by state regulations and/or Plan contracts.

JOB RESPONSIBILITIES:

• Identify changes to State and/or Federal regulations, MCO contracts or NCQA requirements that may affect content of letters generated from Utilization Management and Complaints and Grievances activity.
• Participate in Market Meetings to understand Client requirements and communicate any items that will impact determination or appeal letters.
• Maintain tracking mechanism for current and historical templates for each client. Tracking mechanism is to include client approval and version of template that was approved.
• Perform periodic audit of templates in production to ensure most recent approved version is being used. Coordinate with Client Services and/or Correspondence System to make any necessary changes.
• Coordinate template implementation with Client, Client Services, Correspondence System and Denial Letters groups. This process to include:
• Mock-up of template and submission to Correspondence System group
• Review of template sample to ensure accurate
• Coordinate with Client and/or Correspondence System group revisions needed based on review of sample
• Obtain approval for template
• Coordinate with Correspondence System group to move approved template to production
• Communicate template additions or changes to Denial Letters group
• Perform duties of Operations Document Specialist I, as necessary
• Perform duties of Operations Document Specialist II, as necessary
• Other administrative duties as assigned.

• High School Diploma or equivalent required.
• Previous experience with denial letter templates preferred.
• Knowledge of Centers for Medicare & Medicaid Services (CMS) guidelines for Medicare and Medicaid, National Committee for Quality Assurance (NCQA), State Medicaid regulations or compliance requirements.
• Ability to prioritize and organize multiple tasks.
• Ability to work independently.
• Good PC Skills.
• Excellent analytical ability.
• Strong attention to detail.
• Typing skills of 60+ wpm.
• Excellent verbal and written communication skills.
• Ability to remain organized with multiple interruptions.
• Strong knowledge of Word and Adobe PDF Writer programs.

• 1-3 years experience in related setting.

*BENEFITS:

We offer some of the best benefits in our industry. Below are some of the benefits we offer to DentaQuest employees:

• Medical and Dental Insurance (Includes Domestic Partner Coverage)
• 401(k) Plan with Company Match
• Generous Paid Time Off
• Tuition Reimbursement
• Employer Discretionary Contribution
• Short and Long Term Disability Insurance
• Basic and Supplemental Life Insurance
• Medical and Dependent Care Reimbursement Accounts
• Employee Assistance Program
• Gym membership discounts
• Flexible schedule