Clinical Appeals Analyst

Blue Cross and Blue Shield of North Carolina • Durham, CA

1d • $73,698 - $117,917 • Hybrid

About The Position

We're hiring a Clinical Appeals Analyst to join the Commercial Member Appeals Team! You will be responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. You will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements.

Requirements

• Registered Nurse in the state of North Carolina
• 3 years of clinical experience OR Licensed Practical Nurse, Physical Therapist, Occupational Therapist Licensed in the State of North Carolina and 5 years of clinical experience

Nice To Haves

• Organized with strong ability to manage multiple priorities
• Perform effectively under pressure; resilient in high-stress environments
• Adaptable and able to pivot quickly as priorities change
• Strong verbal communication skills with ability to engage members and providers
• Demonstrates empathy while maintaining professionalism and composure
• Ability to read, interpret, and apply medical policies and clinical criteria
• Experience reviewing medical records to assess completeness and determine next steps
• Strong clinical background
• Proficient computer/navigation skills across multiple platforms

Responsibilities

• Provide clinical consultation with non-clinical staff within the Appeals Department.
• Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.
• Assist with Level 3 appeals as required.
• Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.
• Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.
• Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.
• Initiate claim adjustments on individual cases when necessary.
• Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.
• Identify trends and high-risk issues to make recommendations to address future exposure.
• Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.
• Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.
• Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
• May handle complaints/grievances as defined by the federal government.
• Coordinates with external vendors and provides requested information as requested.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED