Regulatory Complaint Coordinator, Intermediate

at  Blue Shield of California

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 develop a timeline of events and gather 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.

QUALIFICATIONSYOUR KNOWLEDGE AND EXPERIENCE

• Requires a high school diploma or GED
• Requires at least 3 years of experienceRequires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances, at least 1 year of which is Appeals/grievance direct experience, or similar combination

PHYSICAL REQUIREMENTS:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

JOB DESCRIPTIONYOUR ROLE

The Appeals and Grievance Department Regulatory team is responsible for responding to inquiries received directly from our state regulatory agencies. The Regulatory Complaint Coordinator, Intermediate, will report to the Regulatory Complaint Supervisor. In this role you will be responsible for effectively managing your time daily to ensure you are meeting and/or exceeding compliance, quality, and production metrics.

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 develop a timeline of events and gather 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