Appeals Analyst

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. What You’ll Do 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). 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 At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance. $50,337.00 - $80,539.00 Skills Confidentiality, Government Regulation, Law, Medicaid, Medicare, Policies & Procedures, Policy Development, Policy Procedures, Regulatory Compliance, Standards Compliance_____________________________________________________________________ JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected].