Regulatory Affairs Specialist

2 days ago


El Dorado Hills, California, United States Blue Shield of California Full time
About the Role

We are seeking a highly skilled Regulatory Complaint Coordinator, Intermediate-CalPERS to join our team at Blue Shield of California. In this role, you will be responsible for processing and responding to Appeals and Grievances as well as inquiries received directly from CalPERS members, regulatory agencies and CalPERS directly.

As a key member of our team, you will perform comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. You will also be responsible for effectively managing your time daily to ensure you are meeting and/or exceeding compliance, quality, and production metrics.

Your Responsibilities
  • Prepare detailed file summary responses for submission to multiple regulatory, legislative, and accreditation agencies.
  • Evaluate and research end-to-end timelines of member health provider services, claim processing, and other data to determine decision and/or alternative ways to resolve grievance/appeal.
  • Respond to the most complex and highest financial and/or goodwill impact regulatory complaint inquiries.
  • Research data files and develop a timeline of events and gather missing information from third parties such as medical providers, to determine the response to the inquiry.
  • Respond to correspondence addressed to highest level executives regarding issues and/or concerns that an individual (member or non-member) may have.
  • Respond to all CalPERS Request for Health Plan Information (RHPI) requests according to timeliness requirements.
  • Communicate actively with Leadership, other departments, regulatory agencies, etc. to resolve issues relating to CalPERS appeals and grievance processing
  • Other responsibilities/duties as assigned


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