Appeals Analyst (Remote)

Piper Companies; Raleigh (NC); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated Appeals Analyst to join their remote team. This role involves analyzing complex appeals and coding disputes while ensuring compliance with regulatory standards. The ideal candidate will have strong analytical skills and a background in medical terminology and coding. You'll play a crucial role in supporting the decision-making process for appeals, working closely with medical directors and ensuring timely responses. This position offers a competitive salary and comprehensive benefits, making it an exciting opportunity for those passionate about healthcare and compliance.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401k

Paid Time Off

Sick Leave

Holidays

Qualifications

• 3 years of related experience or 5 years without a degree.
• CPC certification required for this role.

Responsibilities

• Analyze and respond to sensitive appeals and coding disputes.
• Document findings and ensure compliance with regulatory standards.

Skills

Analytical Skills

Medical Terminology

Coding Knowledge

Regulatory Compliance

Education

Bachelor's Degree

Advanced Degree

CPC Certification

Job description

Piper Companies is seeking a Appeals Analyst to work remotely for a highly accredited health insurance organization to complete the analysis, review, and submission of complex appeals.

Responsibilities of the Appeals Analyst:

• 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 policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact.
• Prepare files and develops 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 company policies and procedures.
  
  

Qualifications of the Appeals Analyst:

• Bachelor’s degree or advanced degree where required.
• 3 years of related experience
• In lieu of degree, 5 years of related experience
• CPC required
• Must be in approved states of NC (preferred), AL, AZ, AR, CO, FL, GA, ID, IN, IA, KS, KY, LA, MD, MI, MS, MO, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI & WY
  
  

Compensation for the Appeals Analyst:

• Salary Range: $24 - 28/hr based on relative experience
• Comprehensive Benefits including Medical, Dental, Vision, 401k, PTO, Sick Leave if required by law, & Holidays
  
  

This job opens for applications on 5/7/2025. Applications for this job will be accepted for at least 30 days from the posting date.

Keywords: Clinical Appeals Analyst, health insurance, RN, LPN, NC, EMR, NCDOI, NCQA, pharmaceutical companies, health care, complex appeals, claims, analysis, research