Regulatory Complaint Coordinator, Specialist

Job Description

Your Role

The Appeals and Grievances Commercial Regulatory team is responsible for responding to inquiries received directly from our state regulatory agencies. The Regulatory Complaint Coordinator, Specialist will report to the Supervisor of Appeals and Grievances. In this role you will be responsible for oversight of team reviewing, researching, and responding to complex regulatory appeals and grievance cases within established compliance timeframes.

Responsibilities

Your Work

In this role, you will:

• Prepare detailed file summary responses for submission to multiple regulatory, legislative, and accreditation agencies
• Be involved in evaluating and researching 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 the data files and developing a timeline of events, and gathering 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
• Participate in phone calls with regulatory attorneys to explore resolution paths for complex cases
• Provide coaching and feedback to coordinators when applicable as well as case corrections in a timely manner
• Create excel reports to track and trend inventory and case types
• 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
  
  

Qualifications

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 7 years of experience
• Requires at least 6 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances, at least 2 years of which is Appeals/grievance direct experience, or similar combination
• Regulatory Appeals and Grievances experience preferred
• Experience reading regulation, senate bills, and all plan letters (APL) preferred
• 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
  
  

Pay Range:

The pay range for this role is: $ 27.24 to $ 38.13 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.

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.

Please click here for further physical requirement detail.

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.