What are the responsibilities and job description for the Appeals and Grievances Representative, Specialist (Commercial Appeals) position at Blue Shield of California?
Your Role
The 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 Appeals and Grievances 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 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 a minimum of 7 years of experience
- Requires at least 6 years combined operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 2 years direct experience is in Appeals/Grievances, or similar combination
- Commercial Appeals and Grievances experience preferred
- 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
ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
Our Values:
- Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:
At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
Member-facing and approved out-of-state roles remain remote.
Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
