Appeals and Grievances Representative, Intermediate [Apply Now]
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: July 6, 2025
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Job Description:
Your Work In this role, you will: - Answer telephone inquiries
regarding member appeals. - Respond to appeals and grievances and
member reconsiderations. - Research, review and resolve high
level/high priority member grievances, appeals and complaints,
while clarifying issues and educating customers in the process. -
Interpret and explain health plan benefits, policies, procedures
and functions to members and providers. - Administer ongoing
grievance tracking, trending, and reporting for assigned
grievances. - Review incoming appeals and grievances and determine
which area to assign case to or reroute if the issue does not meet
appeal or grievance criteria. - Work in a collaborative manner with
your team to meet compliance timeframes. - Manage your time
independently to ensure that all job duties are completed in a
timely manner. Your Work In this role, you will: - Answer telephone
inquiries regarding member appeals. - Respond to appeals and
grievances and member reconsiderations. - Research, review and
resolve high level/high priority member grievances, appeals and
complaints, while clarifying issues and educating customers in the
process. - Interpret and explain health plan benefits, policies,
procedures and functions to members and providers. - Administer
ongoing grievance tracking, trending, and reporting for assigned
grievances. - Review incoming appeals and grievances and determine
which area to assign case to or reroute if the issue does not meet
appeal or grievance criteria. - Work in a collaborative manner with
your team to meet compliance timeframes. - Manage your time
independently to ensure that all job duties are completed in a
timely manner. Your Knowledge and Experience - Requires a high
school diploma or GED - Requires at least 2 years in health
insurance operations such as I&B, Claims, Customer Services,
Regulatory Affairs and/or Appeals/Grievances or similar combination
- Commercial/IFP health plan knowledge preferred - Requires
knowledge of Microsoft Systems such as Power Point, Excel, and
Word
Keywords: Blue Shield of California, Fairfield , Appeals and Grievances Representative, Intermediate [Apply Now], Customer Service & Call Center , Rancho Cordova, California
