Regulatory Complaint Coordinator, Intermediate

Your Role

The Appeals and Grievance Department Regulatory team is responsible for responding to inquiries received directly from our state regulatory agencies. The Regulatory Complaint Coordinator, Intermediate, will report to the Regulatory Complaint Supervisor. In this role you will be responsible for effectively managing your time daily to ensure you are meeting and/or exceeding compliance, quality, and production metrics.

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

• High School Diploma or GED or 1 year of additional relevant experience in lieu of a diploma
• Requires at least 3 years in health insurance operations such as I&B, Claims, Customer Services, and/or Regulatory Affairs, at least 1 year of which is Appeals/grievance direct experience
• Knowledge of healthcare plans and benefits
• Knowledge and understanding of claims preferred
• Ability to communicate effectively through written and verbal communication

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:

• Prepare detailed file summary responses for submission to multiple regulatory, legislative, and accreditation agencies.
• Be involved in evaluating and researching end-to-end timelines of member health provider services, claim processing, and other data to determine decision and/or alternative ways to resolve grievance/appeal.
• Research, review and respond to inquiries derived from regulatory agencies such as the Dept of Insurance (DOI), the Dept of Managed Health Care (DMHC), the Center for Medicare/Medicaid Services (CMS).
• Responds to regulatory complaint inquiries, which may be written or verbal, prompted by either/or agencies, executive inquiries (for executives), independent medical inquiries, and those prompted by administrative legal hearings
• Research the data files and develop a timeline of events and gather missing information from third parties such as medical providers, to determine the response to the inquiry.
• Responds to inquiries from internal legal counsel, inquiries from various types of consumers on behalf of executives; may represent Blue Shield in legal action (i.e., subpoena responses, regulatory lawsuits, small claims court, etc.), and in administrative law judge hearings.
• Participates in a rotational staffing of phone lines, which satisfies the need to respond to regulator inquiries regarding confirmation of member policy jurisdiction, expedited assistance with their case, or follow-up questions on an open case

Your Work

In this role, you will:

• Prepare detailed file summary responses for submission to multiple regulatory, legislative, and accreditation agencies.
• Be involved in evaluating and researching end-to-end timelines of member health provider services, claim processing, and other data to determine decision and/or alternative ways to resolve grievance/appeal.
• Research, review and respond to inquiries derived from regulatory agencies such as the Dept of Insurance (DOI), the Dept of Managed Health Care (DMHC), the Center for Medicare/Medicaid Services (CMS).
• Responds to regulatory complaint inquiries, which may be written or verbal, prompted by either/or agencies, executive inquiries (for executives), independent medical inquiries, and those prompted by administrative legal hearings
• Research the data files and develop a timeline of events and gather missing information from third parties such as medical providers, to determine the response to the inquiry.
• Responds to inquiries from internal legal counsel, inquiries from various types of consumers on behalf of executives; may represent Blue Shield in legal action (i.e., subpoena responses, regulatory lawsuits, small claims court, etc.), and in administrative law judge hearings.
• Participates in a rotational staffing of phone lines, which satisfies the need to respond to regulator inquiries regarding confirmation of member policy jurisdiction, expedited assistance with their case, or follow-up questions on an open case