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.
What You Bring
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.
Bonus Points
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
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
What You'll Get
The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community.
Work-life balance, flexibility, and the autonomy to do great work.
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.
Learn more
Salary Range
*Based on annual corporate goal achievement and individual performance.
Health insuranceDental insuranceVision insurance401(k)Paid time offPerformance bonusParental leave
Additional Information
Job Description
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.
Bcbsnc · Remote