Job Description

Your Role

The CalPERS team within the Appeals and Grievance Department is responsible for processing and responding to Appeals and Grievances as well as inquiries received directly from CalPERS members, regulatory agencies and CalPERS directly. The Regulatory Complaint Coordinator, Intermediate, will report to the CalPERS Supervisor. In this role you will perform comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. You will also be responsible for effectively managing your time daily to ensure you are meeting and/or exceeding compliance, quality, and production metrics.

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.

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.
• Respond to all CalPERS Request for Health Plan Information (RHPI) requests according to timeliness requirements.
• Communicate actively with Leadership, other departments, regulatory agencies, etc. to resolve issues relating to CalPERS appeals and grievance processing
• Other responsibilities/duties as assigned

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 3 years of experience
• Requires 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
• Experience with the Commercial lines of business, including ASO and CalPERS, is preferred
• Strong communication skills including all written forms of communication
• Knowledge of Microsoft Office programs preferred

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.