Appeals Analyst, CPC Certified

Blue Cross and Blue Shield of North Carolina•Remote Flex - North Carolina, NC

20h•$50,337 - $80,539•Hybrid

About The Position

Blue Cross NC is hiring an Appeals Analyst to join its Coding Disputes Team. The role analyzes and researches appeals, coding disputes, grievances, and coverage or organization determinations, ensuring timely handling, accurate documentation, efficiency, and compliance with applicable regulatory requirements, quality standards, and organizational policies. The analyst addresses customer concerns with a focus on timely resolution and customer satisfaction. The position involves reviewing sensitive matters from members, representatives, providers, media outlets, senior leadership, and regulatory agencies; interpreting health plan benefits, policies, procedures, medical terminology, coding, and functions; preparing files and position statements for external reviews; and developing comprehensive responses that support decisions. The analyst documents investigations and findings, monitors daily reports for timeliness and compliance, and gathers clinical information using established criteria while partnering with Medical Directors, who make clinical appeal and grievance decisions. The role follows a Hybrid Flex or Remote Flex arrangement depending on the nature of the work and distance from Blue Cross NC’s Durham headquarters. Hybrid Flex employees work in the office at least two days per week; Remote Flex employees work virtually with a few in-office visits each year. Onsite expectations are discussed during the interview process.

Requirements

Bachelor’s degree or advanced degree where required.
Three years of related experience.
In lieu of a degree, five years of related experience.
For the coding disputes area, obtain Certified Professional Coder certification within one year of employment.

Nice To Haves

Active AAPC Certified Professional Coder (CPC) certification is strongly preferred.

Responsibilities

Analyze, research, resolve, and respond to confidential or sensitive appeals, coding disputes, grievances, and coverage or organization determinations in accordance with regulatory and accreditation guidelines.
Interpret and explain health plan benefits, policies, procedures, medical terminology, coding, and functions to members and providers.
Exercise independent judgment to make decisions based on Blue Cross NC policies and guidelines, considering potential implications and impacts.
Prepare files and develop Blue Cross NC position statements for external reviews by independent review organizations, benefit panels, and external medical consultants.
Provide comprehensive responses to appeals, coding disputes, and grievances that support the decision and comply with regulatory and accreditation guidelines.
Document investigations, findings, and actions in applicable systems.
Monitor daily reports to ensure service timeliness and compliance.
Gather clinical information using established criteria in corporate medical policies and partner with Medical Directors, who are responsible for clinical appeal and grievance decisions.
Ensure work meets applicable state and federal requirements, accreditation standards, group performance guarantees, and Blue Cross NC and BCBSA policies and procedures.