Appeals & Grievances Analyst

About Delta Dental of Arizona

Delta Dental of Arizona, the state’s #1 dental and vision insurance company, is seeking a conscientious, patient, and team-oriented individual with a sharp eye for detail to join its Compliance team.

The Opportunity: Appeals & Grievances Analyst

Reporting to the Appeals and Grievances Supervisor, the Appeals & Grievances Analyst is responsible for conducting claims research, compliance determinations, and the review and processing of appeals, grievances, and complaints. This role involves close collaboration with claims, sales, and other departments to ensure proper benefits application.

The ideal candidate possesses a thorough understanding of insurance laws and regulations, dental terminology, and has experience interpreting benefit plans.

About You

You bring a few years of experience in insurance, the dental field, or appeals and grievances, demonstrating a strong track record of achieving objectives efficiently and thoroughly. You pride yourself on reliability and meticulous execution, thriving even in repetitive tasks by continuously refining your methods. While analytical, you also possess solid people and relationship-building skills, contributing as a cooperative, helpful, and supportive team player who consistently delivers results.

Essential Functions

• Research incoming appeals, grievances, and complaints, including consideration and reconsideration requests, to accurately categorize them as processed claims (grievances), denied services (appeals or self-funded group requests), or general complaints.
• Collect all necessary data and information, processing it for clinical or contract consideration as required.
• Coordinate case reviews with dental consultants.
• Manage the timely handling and resolution of a high volume of appeals and grievances, adhering to various regulatory and contractual timelines.
• Reconcile information across systems to ensure all member appeals and grievances are logged and tracked accurately.
• Direct external independent reviews to the appropriate independent review organization (IRO).
• Document records in strict accordance with DOI guidance requirements.
• Prepare and manage all monthly and quarterly customer and internal reporting.
• Communicate effectively with internal departments such as Claims, Customer Service, Billing & Eligibility, Marketing, and Professional Relations to facilitate complete and fair reviews of all complaints, grievances, and appeals.

Requirements

• High school diploma or equivalent required
• 2-4 years of related experience
• Knowledge of insurance laws and regulations
• Ability to read and understand benefit plans
• Familiarity with dental terminology
• Thorough understanding of relevant State and Federal laws, DDAZ regulations, and group policies and procedures
• Solid analytical and problem-solving skills
• Excellent verbal and written communication skills
• Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint

About Delta Dental of Arizona

Delta Dental of Arizona's vision is simple: healthier lives for everyone. Our mission is to create a path to better health and wellness, transforming into a multi-line health and wellness organization. We are supported by a foundation that has awarded millions in grants to non-profits aiding vulnerable residents. We foster a collaborative, service-oriented, inclusive culture where employees are valued and celebrated. With approximately 150 employees, contributions are visible and recognized.

Employees receive competitive compensation and comprehensive benefits, including medical, dental, vision, 401(k), student loan assistance, six weeks of paid parental leave, and volunteer PTO.

The starting annual pay for this role ranges from $44,500 - $56,100, depending on experience.

Key skills/competency

• Appeals processing
• Grievance resolution
• Claims research
• Insurance regulations
• Dental terminology
• Benefit plan interpretation
• Compliance
• Data documentation
• Regulatory timelines
• Analytical thinking