Lead Appeals Analyst

Job Description and Duties

Join the Covered California team!

Are you a skilled problem-solver with a passion for navigating complex issues and delivering clear, actionable solutions? Covered California is looking for a Lead Appeals Analyst to join our Consumer Relations and Resolution team, where your expertise in resolving customer appeals, escalations, and administrative processes will make a real impact. This role offers the opportunity to leverage your experience in the insurance or healthcare industry, your knowledge of the Affordable Care Act, your talent and experience in researching customer issues, preparing well-crafted statements and recommendations, and your expertise in implementing effective resolution for identified issues. If you thrive in customer-facing environments, are familiar with using Customer Relationship Management (CRM) systems like Salesforce to maintain customer information, and are proficient with Microsoft Office applications, this position is your opportunity to excel while contributing to meaningful outcomes!

At Covered California, we recognize our employees are our most valuable asset. We have a variety of career fields that help make a difference in the lives of Californians, and we’re looking for talented and enthusiastic individuals to join our team! Learn more about why you should join the .

This position is headquartered in 1601 Exposition Blvd Sacramento, CA 95815. Business travel may be required, and reimbursement considers an employee’s designated headquarters office subject to regulations and bargaining unit contract provisions. Travel expenses associated with commuting to the employee’s office headquarters location are not reimbursable, other than authorized transit subsidies.

NOTE: To be considered for this job opportunity, applicants must be reachable on an employment list, have transfer eligibility, or have reinstatement eligibility. If you are new to California State service and you do not have list eligibility, you must take the exam for this classification. To gain employment list eligibility, please to access the Analyst II exam bulletin.

Possession of minimum qualifications will be verified prior to interview and/or appointment . If it is determined an applicant does not meet the minimum qualifications, the applicant's name may be removed from the eligibility list.

Covered California does not provide visa sponsorship and is not an E-Verify employer.

Effective July 1, 2025, in response to the budget deficit, the Department of Human Resources (CalHR) has implemented the Personal Leave Program 2025 (PLP 2025). PLP 2025 requires that each full-time employee working their assigned work schedule receive a 3 percent reduction in pay in exchange for 5 hours of PLP 2025 leave credits monthly through June 30, 2027.

You will find additional information about the job in the .

Working Conditions

This position may be eligible for telework. In accordance with Government Code section 14200, only employees who reside in California are eligible for telework. The amount of telework is at the discretion of the Department and based on Covered California’s current telework policy. While Covered California supports telework, in-person attendance may be required based on operational needs. Employees are expected to be able to report to their worksite with minimal notification if an urgent need arises, as determined by the Department.

Special Requirements

Statement of Qualifications (SOQ) Instructions: A SOQ is required to apply. The SOQ will be used as a pre-interview screening tool. Applicants who do not follow the SOQ instructions and/or do not answer the prompt as stated below may not be considered.

Artificial Intelligence (AI) tools can be useful in the development of written responses; however, it is important to use these tools responsibly and ethically. Where assistive tools may be used, responses within the SOQ should be your own original work. Applicants must write in their own words and avoid plagiarism. Failure to comply may be cause for disqualification.

A Statement of Qualifications (SOQ) must discuss how your education, training, and experience qualifies you for this position. The SOQ must be no more than two pages in length, 12 pt. Arial font, and must address each of the questions listed below.

1. Describe in detail a time when you used your analytical skills to solve a problem. Please answer each of the following:
   1. What was the problem?
   2. What options did you consider?
   3. How did you evaluate your options?
   4. What recommendations did you make?
   5. What was the outcome?
2. Describe your experience communicating with internal and external customers. What are some essential tools for providing excellent customer service? Please provide an example.
3. Describe your experience applying and communicating policy, regulations, and/or legislation to a diverse audience in a professional setting. What were your strategies for ensuring understanding and how did you handle communication differences? Please provide an example.

Desirable Qualifications

In addition to evaluating each candidate's relative ability, as demonstrated by quality and breadth of experience, the following factors will provide the basis for competitively evaluating each candidate:

• • 2+ years of experience in the insurance/healthcare industry working on customer appeals, escalations and/or complaints, conducting research and analysis of complex issues, and resolution coordination
  • 2+ years of experience interpreting State and Federal laws, Regulations and/or policies
  • 1+ year of experience working with ACA-related policies, programs, or initiatives.
  • 2+ years of experience presenting information verbally and in writing, preparing written statements of position, recommendations, reports and/or findings in a professional setting
  • 2+ years of experience in customer service or call center and familiarity with Customer Relationship Management systems like Salesforce or similar platforms.

Benefits

The State of California offers a comprehensive benefits package that includes Health, Vision, Dental, Retirement, and an array of other options. For more information on the benefits offered by the State of California, please click below:

Pre-Employment Requirements

Background Check: All applicants shall be subject to a pre-employment background investigation. The investigation will consist of completion of a pre-employment questionnaire, fingerprinting, and an inquiry to the Department of Justice and Federal Bureau of Investigation to disclose criminal records.

Incompatible Activities: To maintain our integrity and focus on serving Californians, Covered California adheres to unique conflict of interest restrictions on the outside employment and activities of its board members and staff. If you’re considering a role with us, it’s important to know at the time of your start:

• You must not be employed by or otherwise affiliated with health insurance carriers, other insurers, agents, brokers, health care professionals, health facilities, or health clinics, or trade associations of any of these entities. This also means that you must not hold an active license to sell health insurance in California.
• You must not hold an active license to sell health insurance in California.
• Health care professionals are welcome to join our team, provided you do not receive payment for professional services and do not hold ownership or financial interests in a health care practice.

Required Application Package Documents

The following items are required to be submitted with your application. Applicants who do not submit the required items timely may not be considered for this job:

• Current version of the State Examination/Employment Application STD Form 678 (when not applying electronically), or the Electronic State Employment Application through your Applicant Account at All Experience and Education relating to the Minimum Qualifications listed on the Classification Specification should be included to demonstrate how you meet the Minimum Qualifications for the position.
• Resume is required and must be included.
• Statement of Qualifications -

  Please attach your SOQ to your application. Applications received without a SOQ may not be considered. Resumes and cover letters will not be accepted in place of a SOQ. Please see above “Special Requirements” section for SOQ instructions.