Appeals and Grievances Representative

Blue Shield of California•Rancho Cordova, CA

2d•Hybrid

About The Position

The Appeals and Grievances teams receive, document, investigate, refer, and coordinate grievances, appeals, and complaints. The Appeals and Grievances Coordinator will report to the Appeals and Grievances Supervisor. In this role, you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

Requires a high school diploma or GED
Requires at least 2 years in health insurance operations such as I&B, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
Commercial/IFP/Managed Care health plan knowledge preferred
Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word
Requires a high school diploma of GED
Requires at least 4 years combined health insurance operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 1 year of direct experience in Appeals and Grievances, or similar combination
Dependability – demonstrated success in owning your case load, meeting deadlines, and/or responding timely to inquiries
Trained in written correspondence

Responsibilities

Answer telephone inquiries regarding member appeals.
Respond to appeals and grievances and member reconsiderations.
Research, review, and resolve high level/high priority member grievances, appeals, and complaints, while clarifying issues and educating customers in the process.
Interpret and explain health plan benefits, policies, procedures, and functions to members and providers.
Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
Review incoming appeals and grievances and determine which area to assign the case to or reroute if the issue does not meet appeal or grievance criteria.
Work in a collaborative manner with your team to meet compliance timeframes.
Manage your time independently to ensure that all job duties are completed in a timely manner.
Provide support to member appeal and grievance inquiries within the Commercial, IFP, Medicare, Medi-Cal, FEP, or CalPERS lines of business.
Must be willing to work unplanned overtime or Saturdays as inventory demands may increase.