Appeals Analyst, CPC Certified

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Analyze, investigate, resolve, and address appeals, coding disputes, grievances, and coverage/organization determinations.

• Interpret and clarify health plan benefits, policies, procedures, medical terminology, coding, and functions to both members and providers.

• Apply independent judgment and make decisions in accordance with BlueCross NC policies and guidelines.

• Compile files and create BlueCross NC position statements for external reviews.

• Generate detailed responses that support decisions and adhere to regulatory and accreditation standards.

• Record investigations, findings, and actions in the appropriate systems.

• Review daily reports to ensure timely service delivery and compliance.

• Collect clinical information utilizing corporate medical-policy criteria.

• Collaborate with Medical Directors tasked with clinical appeals and grievance decisions.

• Ensure compliance with NCDOI, CMS, ERISA, NCQA, ASO performance guarantees, and BCBSNC/BCBSA requirements.

⛳️ Requirements

• Bachelor’s degree or advanced degree where applicable, or 5 years of relevant experience in lieu of a degree.

• Minimum of 3 years of relevant experience.

• For the coding disputes area, certification as a professional coder must be obtained within the first year of employment.

• Active AAPC Certified Professional Coder (CPC) certification is highly preferred.

• Capability to analyze, investigate, resolve, and respond to confidential and sensitive appeals, coding disputes, grievances, and coverage/organization determinations.

• Understanding of health plan benefits, policies, procedures, medical terminology, coding, and related functions.

• Ability to adhere to legislative, regulatory, accreditation, quality, and organizational standards.

• Proficient in gathering clinical information using established criteria and collaborating with Medical Directors.

🏝️ Benefits

• Work-life balance, flexibility, and autonomy.

• Medical, dental, and vision coverage.

• Health and wellness programs.

• Parental leave and support.

• Adoption and surrogacy assistance.

• Career development programs.

• Tuition reimbursement for continued education.

• 401(k) match including an annual company contribution.

• Annual Incentive Bonus based on corporate goal achievement and individual performance.

• Paid Time Off (PTO).