Appeals and Grievances Representative, Intermediate
Company: Blue Shield of California
Location: El Dorado Hills
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, Turlock , Appeals and Grievances Representative, Intermediate, Customer Service & Call Center , El Dorado Hills, California
