Grievances/Appeals Intermediate Job

Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California's Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.

We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.

Description:

Researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies and procedures to respondents. Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process. Interprets and explains health plan benefits, policies, procedures and functions to members and providers. Produces complex written correspondence to resolve member grievances, appeals and complaints. Administers ongoing grievance tracking, trending and reporting for assigned grievances. Evaluates all grievances for trend purposes and reports periodic and ad hoc trends to Risk and Quality Management departments. Coordinates next level grievance/appeal meeting with appropriate parties and forwards documentation to the review committee. Establishes and maintains cohesive relationships with assigned IPA partners through telephone, field work and written communication.

• Successfully exceed associate level responsibilities, in addition,
• Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
• Interprets and explains health plan benefits, policies, procedures and functions to members and providers
• Administers ongoing grievance tracking, trending and reporting for assigned grievances
• Consistently performs established performance metrics

Qualifications:

Education/Requirements:

• In addition to skills needed for associate level:
• Ability encompasses proficiency in the skills, internal procedures, and policies needed to satisfactorily complete the full range of assigned tasks.
• Makes decisions based on demonstrated skill proficiency.
• Resolves most questions and problems, and refers only the most complex to higher levels.
• Strong knowledge of CUT, Custom ViewStrong writing skills for document of member concerns and explanation of benefits.
• Minimum Experience Level: Generally requires moderate experience in operations or customer service.
• Typically 1-2 years of related experience successfully demonstrating increasingly higher level work.
• High school diploma or GED equivalent