What are the responsibilities and job description for the Operations Documentation Representative, DentaQuest position at Sun Life Financial?
You are as unique as your background, experience and point of view. Here, you'll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.
Job Description :
Location : This role reports to the Milwaukee office
At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you'll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.
The opportunity :
The Operations Documentation Representative identifies 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.
How you will contribute :
- Participate in Market Meetings to discern client requirements and communicate any items that impacts determination or appeal letters.
- Perform quality audits daily on determination letters.
- Communicate any potential errors identified in auditing determination letters to the identified contact person(s) for the area that generates the document.
- Identify non-compliant determination letters and communicate to Operations Management. Work with UM to have denials overturned if required by State / Plan if letters are non-compliant.
- Coordinate with UM and C&G to submit determination letters for audits in the required timeframe
- Coordinate with Correspondence System team to correct any process issues that may cause errors with determination letters identified during the daily audit.
- Maintain documentation and track / trend errors identified during daily audit process.
- Batch and print member determination letters and prepare for mailing.
- Identify additional process improvements for determination letter process.
- Assist Supervisor with requests from health plans for determination letter information.
- Provide assistance to other departments with determination letter requests.
- Research and coordinate file requests for client audits.
- Perform duties of Operations Document Specialist I, as necessary.
- Perform clinical peer reviews.
- Other duties as assigned.
What you will bring with you :
Do you see yourself in this role even if you haven't checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.
Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you!
Life is brighter when you work at Sun Life
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
We consider various factors in determining actual pay including your skills, qualifications, and experience. In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.
Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com / us to learn more.
At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.
Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email thebrightside@sunlife.com to request an accommodation.
At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.
For applicants residing in California, please read our employee California Privacy Policy and Notice.
Job Category :
Claims - Health & Dental
Posting End Date : 06 / 03 / 2025
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
