Appeals and Grievances Representative, Intermediate
: Job Details :

Your Role

The ​Blue Shield Promise Medi-Cal Appeals and Grievance team researches and resolves member/subscriber grievances, appeals, and interprets and explains health plan benefits, policies, and procedures to Medi-Cal enrollees. The ​Medi-Cal Appeals and Grievance Coordinator​ will report to the ​Operations Supervisor. In this role you will​ be responsible for producing complex written correspondence within timeliness compliance, resolving member grievances and appeals specific to mandates, and meeting Regulatory timeframes​​.

Your Work

In this role, you will:

• Assist with telephone inquiries regarding member appeals.
• Respond to appeals in 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.
• Must be willing to work unplanned overtime or Saturdays as inventory demands may increase.

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
• ​​​General knowledge of applicable legislation/regulations and compliance​. ​
• ​​​​Demonstrated proficiency with free format letter writing required​.
• ​Experience with Microsoft Office applications required​.​

Pay Range:

The pay range for this role is: $ 20.48 to $ 28.67 for California.

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's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.