Regulatory Coordinator

As a member of the Regulatory, Compliance, & Contracts Team, the Regulatory Coordinator processes appeals, complaints, and grievances under the direction of the Regulatory Supervisor This role will analyze, research, and make determinations (decisions) on exception requests, Office of the Insurance Commissioner inquiries (complaints), grievances, and appeals on the member’s behalf, as a well as manage and present relevant information to our formal Appeal’s Committee. They work cross-departmentally, and with our members and external organizations such as any third-party administrators, groups, Better Business Bureau, Attorney General, and the Office of Insurance Commissioner (OIC). The successful candidate will have the ability to work in a confidential manner while partnering across business units and regulatory agencies to meet set service-level agreements.

The Regulatory Coordinator may be assigned to perform other duties as needed to support the department goals.

At Delta Dental of Washington our vision is that all people can enjoy good oral and overall health, with no one left behind. We succeed because of a shared commitment to a set of values that guide everything we do – for our customers, for our communities, and for each other. We are Accountable. We lean in with Courage. We stay Curious. We are Inclusive. We act with Integrity.

We offer a highly competitive medical, dental and vision plans as well offering a generous 401k match and all employees start accruing vacation and sick time from their very first day. We empower employee development through our tuition reimbursement plan, professional development plans, and employee-led communities.

The pay range for this position in Western Washington varies between $44,304.00 – $68,700.00 and for Eastern Washington varies between $45,100.00 - $65,200.00 Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza Corp. intends to offer the selected candidate a base pay within this range, dependent on job-related, non-discriminatory factors such as experience. Base pay will also be adjusted based on the candidate's geographic location.

Essential Responsibilities include the following: The list of responsibilities listed is not intended to be comprehensive. Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza reserve the right to change the responsibilities at any time with or without notice.

Regulatory Standards and Processing

• Create and maintain accurate and timely documentation including complete case files.
• Understand and apply knowledge of applicable government regulations as they apply to individual Appeals and/or complaints, utilizing available resources both internally and external to DDWA.
• Manage Appeals, Complaints, and Grievances, and process in adherence to state and federal regulations, contractual obligations, and established processes.
• Possess a high level of confidentiality and understanding of HIPAA privacy requirements, with the ability to handle information in a confidential manner.
• Work cross-functionally with Dental Consultants, third party administrators, providers, and others as needed to ensure all documentation necessary for review of an appeal, complaint, or grievance is obtained.
• Analyze and research appeal, complaint, or grievance submissions, and inquiries, applying critical thinking, independent judgment, and business sense to conduct a non-biased, accurate and timely investigation. Make a final determination on complaints, and non-committee appeals, based on evidence and contractual obligations.
• Produce comprehensive and professional informal, formal, and legal correspondence including determination letters, responses to the OIC and other agencies, third-party administrators and others as needed within regulatory timeframes and within established processes.
• Manage meeting attendance, agenda, and scheduling for formal Appeals Committee.
• Work with Dental Consultants to conduct clinical review, prepare summary and material for review at the committee meeting, address any questions, facilitate a vote.
• Present and facilitate committee review of non-clinical appeals, prepare summary and material for review at the committee meeting, address any questions, facilitate a vote.
• Document the committee determination, including tracking attendance and member votes, and follow up on any action items as needed.

Additional Responsibilities

• Manage the shared team inbox for external and internal customers, implementing a system for triage.
• Complete intake process for appeals, complaints, grievances, and other items submitted to the Regulatory, Compliance, & Contracts team.
• Create and distribute reports as assigned.
• Maintain and update department guidance and procedure documents, identify and implement opportunities for process improvements.
• Capture changing trends in the type and volume of appeals, complaints and grievances received and communicate to leadership.
• Participate in annual review of master Product templates, updating content and providing meaningful feedback based on experiences throughout the year.

The experience, skills, and education needed to succeed in the position are outlined below. These requirements are representative of the knowledge, skills, and abilities required to successfully perform the essential functions of the role.

• Associate degree (A.A) or equivalent from a two-year college or technical school, or four years dental office related experience and/or training; or equivalent combination of school and experience. Four years of experience working within relevant departments at DDWA may be substituted for education or experience, with the approval of the hiring manager.
• Demonstrate experience in hard copy and electronic document handling, preparation, filing, storage, and version control. Advanced document preparation (formatting, manipulation, verbiage, and proofreading) skills. Broad knowledge of Microsoft Office products and Adobe Acrobat.
• Strong written and verbal communications skills. Exhibits polite and professional communication via phone, e-mail, and mail with a keen attention to detail and accuracy.
• Proven customer service and interpersonal skills, working with a diverse group of internal and external customers.
• Strong time management and organizational skills, ability to prioritize and work independently under stringent timelines.
• Familiarity with database structures, use and data entry practices. Ability to learn new systems, databases, and web applications.
• Proficient with Dental on Demand, DDWA’s claims processing systems, KMS Lighthouse, Customer Support Center, and/or general dental or insurance practices strongly preferred.
• Demonstrate understanding of ethical principles consistent with the mission and values of the organization.

Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

We are committed to the highest standards of information security and HIPAA compliance, ensuring the confidentiality, integrity, and protection of all data. All staff are expected to support this commitment by following relevant policies.