Analyst Jobs

About The Position

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.