Quality of Care Coordinator

Delta Dental • Camp Hill, PA

356d • $41,000 - $83,200 • Hybrid

About The Position

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.

Requirements

• Minimum of 1 year of relevant experience with a high school diploma/GED.
• Background in customer service, provider service, health services, or dental roles within managed care or healthcare environments, including handling escalated or complex issues.
• Proficient in MS Office Suite, with expertise in Excel (e.g., pivot tables, formulas).
• 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.

Nice To Haves

• Experience reading an appeals ledger is a plus!
• 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.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED