Appeals Analyst

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

2d • $50,337 - $80,539 • Hybrid

About The Position

We are seeking an Appeals Analyst to research, analyze, and process appeals, coding disputes, and grievances. In this role, you will ensure work is completed timely, accurately documented, and aligned with legislative and regulatory requirements, quality standards, and organizational policies and procedures. You will also help resolve customer concerns with a focus on timely outcomes and customer satisfaction.

Requirements

• Bachelor’s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• For coding disputes area, certified professional coder must be obtained within 1 year of employment.
• Strong analytical and critical thinking abilities
• Excellent organizational skills
• Ability to prioritize competing deadlines
• Experience working in fast-paced environment
• Proficiency in Microsoft Office and Excel

Nice To Haves

• Certified Professional Coder through AAPC – Highly preferred
• Healthcare Claims adjudication appeals or reimbursement experience – Highly preferred
• Experience with Payor or Provider appeals– Highly Preferred
• Knowledge of Medicare and/or Commercial CMS guidelines - Highly Preferred

Responsibilities

• Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
• Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers.
• Regularly and independently exercise judgement to make appropriate decisions based on BlueCross NC policies and guidelines.
• Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops BlueCross NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines.
• Document extensive investigation, relative findings, and actions in all applicable systems
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met.
• Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances.
• Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees and BCBSNC policies and procedures (to include BCBSA requirements).

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs.
• Parental leave and support plus adoption and surrogacy assistance.
• Career development programs and tuition reimbursement for continued education.
• 401k match including an annual company contribution.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level