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