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Appeals and Grievances Representative, Specialist
2 months ago
Your Role
The Medicare Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Operations Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes while working alongside the Supervisor.
Your Work
In this role, you will:
- Assist with telephone inquiries regarding member appeals
- Have full understanding of applicable legislation/regulations
- Ensure departmental compliance
- Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
- Review incoming appeals and grievances and determine area to assign case to or reroute if the issue does not meet appeal or grievance criteria
- Administer ongoing grievance tracking, trending, and reporting for assigned grievances
- Performs to standard department metrics based on established goals and objectives
- Provide coaching and feedback to coordinators when applicable as well as case corrections in a timely manner
- Manage your time independently to ensure that all job duties are completed in a timely manner
- Work in a collaborative manner with team to meet compliance metrics
Your Knowledge and Experience
- Requires a high school diploma or GED
- Requires at least 6 years combined operations experience such as I&M, Claims, Customer Services, Regulatory Affairs; of which at least 2 years direct experience is in Appeals/Grievances, or similar combination
- Medicare, Medi-Cal, Commercial, or Specialty Appeals and Grievances group knowledge required
- Requires attention to detail, ability to multitask, proficient grammar and strong research skill
- Requires basic job knowledge of systems and procedures obtained through prior work experience or education
- Knowledge of Microsoft Office, specifically, Word and Excel (must be able to enter and manipulate data)
- Willing to work weekends and/or holidays depending on business needs
Pay Range:
The pay range for this role is: $ 26.38 to $ 36.93 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.
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