Appeals and Grievances Representative
4 days ago
The Appeals and Grievances team at Blue Shield of California is responsible for receiving, documenting, investigating, referring, and coordinating grievances, appeals, and complaints. As an Appeals and Grievances Representative, Advanced, you will report to the Appeals and Grievances Supervisor and be responsible for taking incoming telephone calls, reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes.
Your WorkIn this role, you will:
- Answer telephone inquiries regarding member appeals and provide clear and concise information.
- Respond to appeals and grievances and member reconsiderations in a timely and professional manner.
- 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.
- Prepare files for clinician review and ensure accurate and complete documentation.
- Provide guidance to and act as an authoritative source for others within the same skill set.
- Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
- Review incoming appeals and grievances and determine which area to assign the case to or reroute if the issue does not meet appeal or grievance criteria.
- Work collaboratively with the team to meet compliance timeframes and manage time independently to ensure all job duties are completed in a timely manner.
Requires a high school diploma or GED and at least 4 years combined operations experience, such as I&B, Claims, Customer Services, Regulatory Affairs, with at least 1 year of direct experience in Appeals/Grievances or a similar combination. Requires knowledge of Microsoft Systems such as PowerPoint, Excel, and Word.
Pay RangeThe pay range for this role is $22.70 to $31.77 for California.
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