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JOB DESCRIPTION
Your Role

The Medicare Appeals and Grievances team performs comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. The Appeals and Grievance Coordinator will report to the Supervisor of Operations. In this role you will are expected to apply contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services.

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
• Assist in ongoing analytical review of cases to identify trends and provide feedback
• Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating in the process in accordance with CMS Guidelines, contractual obligations, NCQA guidelines and Plan policy
• Interprets and explains health plan benefits, policies, procedures and function to members and providers
• Provider superior customer service through developing and maintaining positive customer relations
• Communicates effectively with other departments to resolve concerns

QUALIFICATIONS
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
• Requires basic job knowledge of systems and procedures obtained through prior work experience or education
• Experience with review and interpretation of CMS Chapters preferred
• Medicare experience strongly preferred
• Knowledge of Microsoft Office; specifically, Word and Excel
• Typically, requires a minimum of 3 years of experience. May require vocational or technical education in addition to prior work experience
  

Pay Range:

The pay range for this role is: $ 20.27 to $28.38 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.

ABOUT THE TEAM
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!

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.

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain an accommodation within 30 days, your offer will be rescinded.