Appeals Analyst, CPC Certified — Health Care Disputes

Blue Cross and Blue Shield of North Carolina; Chapel Hill (NC); Hybrid; USD 50,000 - 81,000; Full time

Job summary

Blue Cross NC is hiring an Appeals Analyst to join the Coding Disputes Team. You will analyze and research appeals, coding disputes and grievances, ensuring timely resolution and accurate documentation in line with regulatory requirements.

The role emphasizes collaboration with Medical Directors, preparation of position statements, and maintaining quality standards while supporting customer satisfaction and compliance across state and federal guidelines.

Qualifications

• Bachelor's degree or advanced degree required.
• 3 years of related experience; in lieu of degree, 5 years of related experience.
• For coding disputes area, CPC certification must be obtained within 1 year of employment.

Responsibilities

• Analyze, research, resolve and respond to appeals, coding disputes, grievances and coverage/organization determinations.
• Analyze, interpret, and explain health plan benefits, policies, procedures, and medical terminology to members and/or providers.
• Regularly exercise judgement to make appropriate decisions based on policies and guidelines.
• Prepare files and develop BlueCross NC position statements for external reviews by independent review organizations, benefit panels and external medical consultants.
• Provide comprehensive appeals responses that support the decision and comply with regulatory guidelines.
• Document extensive investigation, findings, and actions in all applicable systems.
• Monitor daily reports to ensure service timeliness and compliance.
• Gather clinical information using established criteria and partner with Medical Directors for clinical decisions.
• Ensure timeliness, quality, and efficiency to comply with state and federal accreditation standards.

Skills

Analytical thinking

Regulatory compliance

Communication

Research skills

Education

Bachelor's degree or advanced degree

Job description

Blue Cross NC is hiring an Appeals Analyst to join the Coding Disputes Team. You will analyze and research appeals, coding disputes and grievances, ensuring timely resolution and accurate documentation in line with regulatory requirements.

The role emphasizes collaboration with Medical Directors, preparation of position statements, and maintaining quality standards while supporting customer satisfaction and compliance across state and federal guidelines.