Hybrid Regulatory Complaints & Appeals Coordinator

Blue Shield of California; California; Hybrid; USD 30,000 - 41,000; Full time

Job summary

Blue Shield of California is seeking a Regulatory Complaint Coordinator, Intermediate, within the Appeals and Grievance Department to respond to inquiries from state regulatory agencies. The role reports to the Regulatory Complaint Supervisor and emphasizes timely, compliant handling of escalations and data-driven decision making.

Ideal candidates bring 3+ years in health insurance operations, including appeals/grievances, with knowledge of healthcare plans and claims.

Qualifications

• High School Diploma or GED required; experience in lieu acceptable.
• At least 3 years in health insurance operations (I&B, Claims, Customer Services, Regulatory Affairs).
• At least 1 year of Appeals/grievance direct experience.
• Knowledge of healthcare plans and benefits; understanding of claims preferred.

Responsibilities

• Prepare detailed file summary responses for regulatory, legislative, and accreditation agencies.
• Evaluate end-to-end timelines of member health services, claims, and data for grievance/appeal resolution.
• Research inquiries from regulatory agencies such as DOI, DMHC, CMS.
• Respond to inquiries from internal counsel or consumers; may represent Blue Shield in legal actions.
• Participate in rotational staffing of phone lines to respond to regulator inquiries.

Skills

I&B

Claims

Customer Service

Regulatory Affairs

Appeals/Grievance

Education

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

Job description

Blue Shield of California is seeking a Regulatory Complaint Coordinator, Intermediate, within the Appeals and Grievance Department to respond to inquiries from state regulatory agencies. The role reports to the Regulatory Complaint Supervisor and emphasizes timely, compliant handling of escalations and data-driven decision making.

Ideal candidates bring 3+ years in health insurance operations, including appeals/grievances, with knowledge of healthcare plans and claims.