Appeals and Grievances Representative, Advanced

Your RoleThe Provider Dispute Resolution Team is looking for an Advanced Provider Dispute Resolution Coordinator that can research, review and resolve high level/high priority provider grievances, appeals and complaints, while clarifying issues and educating providers in the process. The Advanced Provider Dispute Coordinator will report to the Medicare Supervisor. In this role, the coordinator should be able to make independent decisions and appeal determinations. Be a subject matter expert in guidelines and documentation, participating in special projects, and identifying trends or issues driving provider abrasion. The candidate should effectively manage their time and prioritize their workload to ensure compliance timeframes and project deadlines are met.Your WorkIn this role, you will:Process provider appeals and correspondence, requiring minimal support, explaining health plan benefits, policies, procedures and functions to providers.Proactively identify issues and execute corrective action on provider appeals.Identify and triage appeals to appropriate areas.Respond in writing to providers regarding appeal outcomes.Consistently perform at established performance metrics.Make independent decisions based on demonstrated skill proficiency.Introduce workflow changes and request changes as needed.Demonstrate flexibility, adaptability and support change in business needs.Independently use available resources, documentation and tools.Understand business needs and support efforts to improve team performance.Effectively partner with vendor teams and other departments.Conduct chair side coaching.

Your Knowledge and ExperienceRequires a high school diploma or GEDRequires at least 3 years combined operations experience such as I&M, Claims, Customer Services, Regulatory Affairs; of which at least 2 years direct experience is in Appeals/Grievances, or similar combinationRequires claims processing, including adjustments, interest accuracy proficiency, general suspense and back-end claims experienceStrong skill set of Microsoft Office applicationsDemonstrated experience with free format letter writingPreferred previous appeal and or dispute experiencePreferred knowledge of applicable legislation/regulations and compliancePreferred knowledge of following systems - Facets, DocDNA, Smartcomm, Documentum, CLMS, CMS Pricers = 3M Pricer, DRG Pricer, SNF Pricer, CareWebQI.

Pay Range:The pay range for this role is: $ 22.69 to $ 31.77 for California.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's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.