Appeals And Grievances Coordinator, Intermediate For Promise

Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!

Your Role

The Appeals & Grievance Medi-Cal team performs comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate & appropriate resolution in accordance with guidelines established by the appropriate regulators. The Appeals & Grievance Coordinator will report to the Supervisor of the Appeals & Grievances Medi-Cal Team.

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
• Research, review, and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating in the process in accordance with DHCS and DMHC guidelines, contractual obligations, NCQA guidelines and Plan policy
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers
• Provide superior customer service through developing and maintaining positive customer relations
• Communicate effectively with other departments to resolve concerns
• Assists in ongoing analytical review of cases to identify trends and provide feedback
• Generate appropriate/accurate acknowledgement and resolution letters.
• Document all relative findings and actions in all applicable systems
• Perform to standard department metrics based on established goals and objectives
• Demonstrate flexibility by working overtime which may entail weekends and/or holidays dependent on business and inventory needs
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met
• Perform additional duties and projects as assigned by Management

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
• Medicare and Medi-Cal experience strongly preferred
• Requires basic job knowledge of systems and procedures obtained through prior work experience or education
• AGD experience preferred with ability to interpret DHCS and DMHC guidance
• Knowledge of Microsoft Office, specifically, Word and Excel (must be able to enter and manipulate data)

Our Values

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals