Associate General Counsel, Sr Principal - Appeals and Grievances

Your Role

The Medical Care Solutions team is responsible for various client support within Blue Shield of California, including the Appeals and Grievances Department and Customer Service Team, Behavioral Health, Medical Policy, Utilization Management, Pharmacy and Regulatory Filings. The Associate General Counsel, Sr. Principal, will report to the Managing Senior Director. In this role you will support the Appeals and Grievances Department in its interactions with state regulators, specifically by assisting with cases related to member appeals of health plan denials and provide legal support for operational and policy projects related to customer service outcomes from member appeals.

Your Work

In this role, you will:

Coordinate with and support the Appeals and Grievances Department (AGD) to analyze and respond to complex member appeals from the Department of Managed Health Care Help Center.

Conduct legal research and guide staff research into member cases and assist with outreach to internal departments to support the AGD Regulatory and Clinical teams.

Conduct legal research and analysis on applicable laws and regulations, including those raised by the regulator through requests for information (RFIs) and requests for health plan information (RHPIs).

Support development of policies and procedures to identify gaps and adjust for trends and lessons learned from complaints and appeals cases, for AGD, Utilization Management and Customer Service teams.

Meet with state regulators and serve as lead as necessary to discuss appeals cases, policies and procedures, and ongoing administrative/legal issues.

Participate in discussions with internal leadership and external regulator leadership regarding escalated disagreements related to statutory interpretation and process.

Provide support to more senior attorneys, as needed.

Coordinate with other Law Department subject matter experts, including the Litigation team, and liaise with outside counsel as needed.

Assist in the development and implementation of legal strategies to protect the company's interests and manage risks.

Coordinate with other departments internally to gather information for assigned tasks.

Influence others regarding policies, practices, and procedures.

Become proficient in assigned area/specialty and develop proficiency in one additional area/specialty in department

Create, foster, and maintain relationships with internal clients and external stakeholders and constituents that enhance the Company’s reputation as a health plan, employer, and corporate citizen.

Work independently, under the guidance of more senior attorneys who will sometimes review recommendations and decisions and communicate effectively with managing senior director.

Other duties as assigned

Your Knowledge and Experience

Requires a juris doctorate degree from a law school accredited by the American Bar Association or Committee of Bar Examiners of the State of California

Requires active member of the California bar, or active licensee in good standing of a bar of a United States state or the District of Columbia who maintains Registered In-House Counsel status with the State Bar of California

Requires a successful track record of at least five years of experience providing legal advice on relevant areas of the law (e.g., corporate, privacy, health care regulatory, litigation, contracts, et al) at a law firm or in-house health law department, including state or federal regulatory agency

Requires excellent communication skills, both written and verbal, as well as relationship building skills to collaborate with and influence all relevant stakeholders, both internal and external

Requires strong independent judgment, problem-solving, critical, and analytical thinking skills, including a “moral compass” and high integrity

Requires ability to work with minimal supervision, to multi-task, and to deliver a high-quality work product in a highly regulated, demanding, and constantly changing corporate environment required

Requires ability to lead when appropriate and to work both independently and collaboratively on teams

Requires proficiency in Microsoft Word, Excel, PowerPoint, and Outlook

Requires ability to communicate complex legal issues to non-lawyer clients and regulator staff

A combination of law firm, in-house counsel and/or state regulator experience is preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.