Appeals and Grievances Representative

Your Role

The Appeals and Grievances teams receive, document, investigate, refer, and coordinates 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.

Your Knowledge and Experience

Appeals and Grievances Representative, Intermediate

• 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

Pay Range for CA: $21.73 to $30.03

Pay Range for Bay Area: $24.50 to $34.31

Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield Salaries are based on a variety of factors including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Appeals and Grievances Representative, Advanced

• 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

Pay Range for CA: $24.78 to $34.70

Pay Range for Bay Area: $27.94 to $39.12

Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield Salaries are based on a variety of factors including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Your Work

In this role, you will:

• 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 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

Your Work

In this role, you will:

• 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 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