New

Quality of Care Coordinator

Delta Dental of California
$40,500 - $84,800
dental insurance, paid time off, paid holidays, tuition reimbursement, 401(k), employee discount
United States, Georgia, Alpharetta
Apr 04, 2025
JOB DESCRIPTION The Quality of Care Coordinator plays a pivotal role in ensuring the highest standards of care and service by analyzing and addressing quality complaints and referrals across all lines of business. This position is responsible for managing the complaint response process to deliver timely resolutions and effective communication with all stakeholders. This hybrid role requires flexibility to attend in-person office events, such as team-building activities, meetings, and town halls, as needed. RESPONSIBILITIES Record and classify quality of care/service complaints and potential quality referrals from members or clinicians (internal/external) to determine administrative or clinical nature. Review clinical and dental records for completeness; coordinate with providers to finalize records for Dental Consultant review. Conduct research to identify relevant clinical guidelines, plan policies, regulatory requirements, and applicable rules (DMHC/DHCS, EOC). Summarize cases, articulate complainant concerns, and present findings to the Dental Consultant for further evaluation. Assign clinical reviews for inquiries involving quality of care issues. Collaborate with Clinical Quality Specialists, Dental Consultants, and other staff to ensure clinical issues are effectively resolved. Prepare comprehensive case files for external reviews, including Independent Review Entity (IRE) submissions. Investigate root causes of complaints and coordinate with operational teams to implement appropriate resolutions. Communicate resolutions to complainants professionally via phone or written correspondence. QUALIFICATIONS Ability to work a starting schedule of Monday through Friday, 8:00 a.m. to 4:45 p.m. and report to the office on an as needed basis. Minimum of 1 year of relevant experience with a high school diploma/GED. Background in customer service, provider service, health services within dental insurance, dental office, or healthcare environment, including handling escalated or complex issues. Dental insurance or dental office experience preferred. Proficient in MS Office Suite, with expertise in Excel (e.g., pivot tables, formulas). Experience reading an appeals ledger is a plus! Strong written and verbal communication skills. High attention to detail and organizational skills. Proven problem-solving and critical thinking abilities to research and resolve complex issues. Passionate about enhancing the healthcare experience for members. Motivated by helping others and seeing the positive impact of your work. Resourceful, analytical, and adept at identifying root causes to resolve problems effectively. Base Pay Information The national base pay range is a good faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications, and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. Pay Grade 16. $40,500 - $84,800 ADDITIONAL INFORMATION Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes: Competitive base and incentive pay 401(k) with robust matching and non-matching contributions Rich medical & pharmacy benefits 100% employer-paid dental and vision benefits Holistic wellbeing program with deep financial incentives Generous paid time off plus 12 paid holidays and your birthday off Culture of growth and learning: career development; tuition reimbursement; recognition program Family support: adoption assistance, fertility treatment, child, elder & pet care assistance Social responsibility and volunteer opportunities Employee discount program Fair Chance Ordinances and Criminal Background Considerations Qualified applicants with arrest or conviction records will be considered for employment in accordance with all applicable federal, state, and local laws, including, but not limited to, fair chance and anti-discrimination ordinances. At Delta Dental, we maintain a strict stance on theft, fraud, and violent crimes. For positions involving driving, we enforce heightened standards regarding driving records. Each individual criminal background check is evaluated on its merits, taking into account the time elapsed since the conviction, evidence of personal development and rehabilitation, and any potential risk posed to our business operations, employees, customers, or vendors. Important Work Authorization Information Please note, Delta Dental will not sponsor applicants for work visas for this position. #LI-Hybrid ABOUT THE TEAM Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, Hawaii, Maine, Nebraska, New Hampshire, North Dakota, Oklahoma, Vermont, West Virginia, Wyoming, Washington DC, Puerto Rico or other US Territories or outside of the United States at this time.