Appeals and Grievances Representative

Your Role

The Appeals and Grievances teams receive, document, investigate, refer, and coordinates grievances, appeals and complaints. The Appeals and Grievances Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

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.

• Provide support to member appeal and grievance inquiries within the Commercial, IFP, Medicare, Medi-Cal, FEP, or CalPERS lines of business

• Must be willing to work unplanned overtime or Saturdays as inventory demands may increase

Future Opportunities

Great talent is always in demand at Blue Shield of California. While there is not a current opening associated with this posting, we are proactively building a network of qualified candidates for future opportunities. We encourage you to apply and stay connected for upcoming roles that align with your skills and interests.

Qualifications

Your Knowledge and Experience

Appeals and Grievances Representative, Intermediate

• High School Diploma or GED or 1 year of additional relevant experience in lieu of a diploma

• Requires at least 3 years in health insurance operations such as I&B, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
• Commercial/IFP/Managed Care health plan knowledge preferred
• Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word

Pay Range for CA: $21.73 to $30.03

Pay Range for Bay Area: $24.50 to $34.31

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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Appeals and Grievances Representative, Advanced

• High School Diploma or GED or 1 year of additional relevant experience in lieu of a diploma
• Requires at least 5 years combined health insurance operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 1 year of direct experience in Appeals and Grievances, or similar combination
• Dependability – demonstrated success in owning your case load, meeting deadlines, and/or responding timely to inquiries
• Trained in written correspondence

Pay Range for CA: $24.78 to $34.70

Pay Range for Bay Area: $27.94 to $39.12

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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. 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 listen and communicate effectively, showing empathy by understanding others' perspectives.
• 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

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.

• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.

• 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.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.