Appeals and Grievances Representative, Intermediate

Company: Blue Shield of California
Location: El Dorado Hills
Posted on: October 8, 2024

Job Description:

Your Role
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The Appeals and Grievances Pharmacy team researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies, and procedures to appellant. The AGD - Intermediate coordinators will report to the team's Operational Supervisor. In this role you will clarify issues, educate members in the process and interpret/explain health plan benefits, policies, procedures and functions to members and providers. You will be responsible for producing complex written correspondence to resolve member grievances, appeals and complaints.
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Your Work
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In this role, you will:

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• Assist with telephone inquiries regarding member appeals.
  
• Respond to member appeals, grievances, and complaints.
  
• Clarify and educate members on appeals and grievance policies.
  
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
  
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
  
• Interpret and consistently perform at established Intermediate performance metrics including quality and production standards.
  
• Make independent decisions based on demonstrated skill proficiency and use available resources, documentation, and tools.
  
• Demonstrate flexibility, adaptability and support change in business needs that are made to improve team performance.
  Your Knowledge and Experience
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  • 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
    
  • General knowledge of applicable legislation/regulations and compliance
    
  • Basic knowledge of Microsoft Office applications
    
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    Pay Range:
    The pay range for this role is: $ 20.48 to $ 28.67 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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Keywords: Blue Shield of California, Redwood City , Appeals and Grievances Representative, Intermediate, Other , El Dorado Hills, California