Remote Medicare Advantage Appeals and Grievances Specialist

The Medicare Advantage Appeals and Grievances Customer Experience Specialist provides a world class customer service experience through processing and resolution of Medicare Advantage (MA) member, member representative, or provider appeals and grievances. May also process and resolve member, representative, provider, and other Blue Plan inquiries.

“This position is eligible to work onsite, remote, or hybrid (9 or more days a month onsite) in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.”

o This role includes hours that can range from 8:00 a.m. to 8:00 p.m. and can include weekend hours from October 1 through March 31.
o The position will start approximately April 14, 2025

Why Join Us?

• Family Comes First: Total rewards package that promotes the idea of family first for all employees; including paid time off and family first leave.
• Professional Growth Opportunities: Advance your career with ongoing training and development programs both through our internal Blue University and external opportunities.
• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
• Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
• Balance: paid vacation and sick leave with paid maternity and paternity available immediately upon hire

Compensation

$26.34- $32.93
Non-Exempt Grade 13

• Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.

• Create and compose correspondence in response to MA member, member representative or provider appeals and grievances cases to ensure all regulatory guidelines are met.
• Interpret, analyze, and review all MA benefit offerings and their relevant language, corporate policies, administrative and operating procedures, information systems, and regulatory guidance to address a variety of issues which may not be clear or direct.
• Manage time to optimize and prioritize work to ensure goals (internal, regulatory, etc.) are met in a fluctuating environment.
• Use discretion to make judgment calls determining appropriate sources, directions, and parameters necessary to review and resolve issues in an extremely diverse, complex, and challenging business and regulatory environment. This can include interaction with a variety of internal and/or external contacts. Develop effective working relationships with staff at every level within BCBSKS, other Plans, CMS Caseworkers or Account Manager, relevant suppliers and contractors, providers, and/or members and their representatives.
• Serve as a backup to the MA Customer Experience Representatives as business needs dictate. This involves researching, resolving, and responding to inquiries and correspondence via telephone, written and email communication. Inquiries may be regarding MA benefits, eligibility, coverage and plan changes, payments, claims, prior authorizations, appeals, and grievances.
• Perform additional duties as required, including any special projects.

• Ability to interact positively with internal and external customers while demonstrating empathy, adaptability, and listening skills.
• Ability to listen, talk type and perform research simultaneously using various research channels.
• Excellent reasoning, analytical, problem-solving skills, and sound judgment.
• Capacity to conduct extensive research, provide analyses and solutions to unusual or recurring issues, at times using discretion.
• Efficiency in managing dissimilar issues, determining priorities and meeting regulatory and/or company deadlines.
• Advanced human relations, oral and written communication skills.
• Ability to maintain strict confidentiality in handling data related to job duties.
• Able to work collaboratively and cooperatively as a team member.
• Ability to work within a self-initiated environment with little supervision.
• Ability to achieve production-based performance goals.
• Technical skills to effectively use computer programs and troubleshoot simple computer issues independently or with direction.
• Ability to adhere to a rigid schedule and have regular and predictable attendance.
• Obtain and maintain any departmental or legally required certifications (e.g. CMS or BCBSA requirements).
• Upon completion of training:
  • Working knowledge of Blue Cross and Blue Shield of Kansas’ MA and other relevant systems is required.
  • Detailed knowledge of MA line of business and regulations governing MA appeals and grievances is required.

• High school diploma or equivalent.
• Two years of customer service experience.
• Three years of MA Appeals and Grievances experience.

• College or continuing education courses in communications and/or medical related fields.
• Two years of navigating multiple computer systems simultaneously.
• Two years of MA or other call center or production-based customer service experience.
• Blue Plan experience.

• Communicate by telephone 95 percent of the workday.
• Use a personal computer in a stationary position at least 95 percent of the workday.