Appeals and Grievances Coordinator, Intermediate for Medicare Operations

o About Blue Shield of California: For more than 80 years, Blue Shield has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 7,500 employees, more than $21 billion in annual revenue and 4.5 million members. The company has contributed more than $500 million to the Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield is headquartered in Oakland, California with 21 additional locations including Sacramento, Los Angeles, and San Diego.
o Our Benefits: At Blue Shield you can expect a comprehensive benefits program that offers choice and flexibility for our diverse workforce. These programs and resources include: Medical, Dental, and Vision plan benefits, 401(k) with employer match, paid time off (PTO), earned sabbatical time, paid nonprofit volunteer time, flexible work program, free online education, tuition reimbursement, a wellness reimbursement program, 12 weeks paid parental leave, and more.


Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us!

Your Role

The Medicare Appeals & Grievance Coordinator performs comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate & appropriate resolution in accordance with CMS guidelines . The Appeals & Grievance Coordinator will report to the Medicare Appeals & Grievance Supervisor . In this role you will r esearch, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating in the process in accordance with CMS Guidelines, contractual obligations, NCQA guidelines and Plan policy .

Your Work

In this role, you will:
  • Assist with telephone inquiries regarding member appeals
  • Respond to appeals in 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
  • Generates appropriate/accurate acknowledgement and resolution letters.
  • Accountable for monitoring daily reports to ensure service timeliness and compliance is met
  • Provide superior customer service through developing and maintaining positive customer relations
  • Communicates effectively with other departments to resolve concerns. Assists in ongoing analytical review of cases to identify trends and provide feedback
  • Documents all relative findings and actions in all applicable systems
  • Performs to standard department metrics based on established goals and objectives
  • Demonstrate flexibility by working overtime which may entail weekends and/or holidays dependent on business and inventory needs


Your Knowledge and Experience

  • Requires a high school diploma or GED
  • Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
  • Medicare experience strongly preferred
  • Requires basic job knowledge of systems and procedures obtained through prior work experience or education
  • Experience with review and interpretation of CMS Chapters preferred
  • Must be willing and able to work weekends and/or holidays as needed
  • Knowledge of Microsoft Office, specifically, Word and Excel (must be able to enter and manipulate data)

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 be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes
  • Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals

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.

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.
COVID-19 update: From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a federal contractor and a health care company, Blue Shield requires all employees to be fully vaccinated prior to start date as a condition of employment and provide proof of vaccination status. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date
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