Appeals Analyst

Motion Recruitment; Durham (NC); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company in the health insurance sector is looking for an Appeals Analyst. This remote role requires candidates to reside in North Carolina or select states. Responsibilities include analyzing appeals and ensuring compliance with regulations. Ideal candidates will have a Bachelor's degree and relevant experience, with CPC Certification preferred.

Qualifications

• At least 3 years of related experience.
• In lieu of degree, 5 years of related experience.

Responsibilities

• Analyze and resolve appeals, coding disputes, and grievances.
• Explain health plan benefits and medical terminology.
• Document investigations and findings in relevant systems.

Skills

CPC Certification

Analytical Skills

Communication

Education

Bachelor’s degree

Job description

Join to apply for the Appeals Analyst role at Motion Recruitment.

Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for an Appeals Analyst. They serve over 4 million customers and employ more than 5,000 staff dedicated to providing innovative solutions that simplify healthcare, improve efficiency, and reduce costs.

Location: Remote, but candidates must reside in North Carolina or one of the following states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, or Wyoming.

Contract Duration: 12 months, with potential for contract to hire.

Required Skills & Experience

• Bachelor’s degree or higher where required.
• At least 3 years of related experience.
• In lieu of degree, 5 years of related experience.
• Must be CPC Certified.

Desired Skills & Experience

• Care Radius experience is a plus.
• Facets experience is a plus.

Responsibilities

• Analyze, research, resolve, and respond to confidential appeals, coding disputes, grievances, and coverage determinations from members, providers, media, senior leadership, and regulatory agencies, adhering to regulatory and accreditation standards.
• Explain health plan benefits, policies, procedures, and medical terminology to members and providers.
• Exercise judgment independently to make decisions based on policies and guidelines, ensuring business continuity.
• Prepare files and develop position statements for external reviews by independent organizations, benefit panels, and medical consultants.
• Provide comprehensive responses to appeals, coding disputes, and grievances, ensuring compliance with regulations.
• Document investigations and findings in relevant systems.
• Monitor daily reports to ensure timely and compliant service delivery.
• Gather clinical information using established criteria, collaborating with Medical Directors for clinical decisions.
• Ensure timeliness, quality, and efficiency to meet state and federal accreditation standards and client policies.
• Pass drug tests and background checks as required.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Contract