Appeals Analyst

Experis; Durham (NC); Remote; USD 55,000 - 75,000; Full time

Job summary

An innovative firm is seeking an Appeal Analyst to join their dynamic team. This remote position involves analyzing and resolving sensitive appeals and coding disputes while ensuring compliance with regulatory standards. The ideal candidate will possess strong analytical and communication skills, along with a Bachelor’s degree and CPC certification. This role offers the opportunity to make impactful decisions and contribute to the quality of healthcare services. If you’re passionate about making a difference in the healthcare industry, this position is perfect for you.

Qualifications

• Bachelor’s degree or higher where required.
• 3 years of related experience or 5 years in lieu of degree.
• CPC certification required.

Responsibilities

• Analyze and resolve appeals, coding disputes, and grievances.
• Prepare files and develop position statements for external reviews.
• Monitor compliance with State and Federal accreditation standards.

Skills

Analytical Skills

Research Skills

Communication Skills

Judgment and Decision Making

Education

Bachelor’s Degree

CPC Certification

Job description

Our client is seeking an Appeal Analyst to join their team.

Appeal Analyst

Contract to Hire

Remote

Responsibilities:

1. Analyze, research, resolve, and respond to confidential/sensitive appeals, coding disputes, grievances, and coverage/organization determinations from members, members' representatives, providers, media outlets, senior leadership, and regulatory agencies, following established regulatory and accreditation guidelines.
2. Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding, and functions to members and/or providers.
3. Exercise judgment independently to make appropriate decisions based on BlueCross NC policies and guidelines, acting decisively to ensure business continuity with awareness of all possible implications and impact.
4. Prepare files and develop BlueCross NC position statements for external reviews by independent review organizations, benefit panels, and external medical consultants.
5. Provide comprehensive responses to appeals, coding disputes, and grievances that support decisions and comply with regulatory and accreditation standards.
6. Document investigations, findings, and actions in all applicable systems.
7. Monitor daily reports to ensure service timeliness and compliance.
8. Gather clinical information using established criteria from corporate medical policies and partner with Medical Directors responsible for clinical appeals/grievances decisions.
9. Ensure timeliness, quality, and efficiency in all work to meet applicable State (NCDOI) and Federal (CMS, ERISA, etc.) accreditation standards.

Hiring Requirements:

1. Bachelor’s degree or higher where required.
2. 3 years of related experience.
3. In lieu of degree, 5 years of related experience.
4. CPC certification required.

If this role interests you and you’d like to learn more, click 'apply now' and a recruiter will contact you to discuss this opportunity. We look forward to speaking with you!

About ManpowerGroup, Parent Company of: Manpower, Experis, Talent Solutions, and Jefferson Wells

ManpowerGroup (NYSE: MAN) is a leading global workforce solutions company that helps organizations adapt in a fast-changing world of work by sourcing, assessing, developing, and managing talent. We serve hundreds of thousands of organizations annually, providing skilled talent and sustainable employment across various industries. Our brands—Manpower, Experis, Talent Solutions, and Jefferson Wells—generate value for candidates and clients in over 75 countries and territories, with a history spanning over 70 years. We are recognized for our commitment to diversity and inclusion, being named one of the World's Most Ethical Companies for 13 consecutive years in 2022, reaffirming our position as a preferred employer for in-demand talent.