Appeals Analyst, CPC Certified

NC Health Affiliates; United States; Hybrid; USD 50,000 - 81,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Tuition reimbursement

401k match

Job summary

Blue Cross NC is hiring an Appeals Analyst to join the Coding Disputes Team. You will complete analysis and research to process appeals, coding disputes and grievances, ensuring timely resolution and thorough documentation.

You will interpret health plan benefits, policies, medical terminology, and coding, communicating clearly with members and providers. The role requires independent judgement and collaboration with Medical Directors to resolve clinical matters.

Qualifications

• 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, CPC certification within 1 year of employment.

Responsibilities

• Analyze, research, resolve and respond to appeals, coding disputes and grievances with stakeholders.
• Explain health plan benefits, policies and coding to members/providers.
• Exercise judgement to make decisions per BlueCross NC policies and guidelines.
• Prepare position statements for external reviews.
• Provide comprehensive responses that comply with guidelines.
• Document investigations and actions in systems.
• Monitor daily reports for timeliness and compliance.
• Gather clinical information with Medical Directors’ involvement.

Skills

Analytical thinking

Research skills

Decision making

Communication

Education

Bachelor's degree

Advanced degree (preferred)

Job description

We're hiring an Appeals Analyst to join the Coding Disputes Team! Complete analysis and research required to process appeals, coding disputes and grievances. Ensure timeliness, accurate documentation, and efficiency in all work to comply with applicable legislative and regulatory requirements, quality standards and organizational policies and procedures. Address customer concerns with a focus on timely resolution 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 (Preferred qualifications)

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

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

Where You'll Work

Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that's flexible, connected, and future focused.

In a Hybrid-Flex role, you'll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

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