Clinical Appeals Analyst

Blue Cross and Blue Shield of North Carolina; United States; Hybrid; USD 74,000 - 118,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k with employer match

Paid Time Off (PTO)

Parental leave and adoption support

Job summary

Blue Cross and Blue Shield of North Carolina is seeking a qualified nurse or licensed professional to lead the analysis and resolution of complex appeals and grievances. You will ensure compliance with NCDOI, NCQA, CMP and relevant regulations while delivering timely, high-quality outcomes.

You will provide clinical consultation to non-clinical staff, coordinate the appeals process, handle Level 3 appeals as needed, and document determinations for appellants and stakeholders.

Qualifications

• Active North Carolina nursing license (RN) or applicable LPN/PT/OT license with clinical experience.
• Minimum 3 years of clinical experience.
• Ability to work in a fast-paced, deadline-driven environment.

Responsibilities

• Provide clinical consultation with non-clinical staff within Appeals Department.
• Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, CMP, contract provisions, NCDOI and NCQA requirements.
• Assist with Level 3 appeals as required.
• Analyze complex/non-routine member and provider appeals and grievances for all lines of business (excluding FEP).
• Identify documentation from external sources and present analysis to physician committees and BCBSNC leadership.

Skills

3 years of clinical experience

Attention to detail

Fast-paced environment

Education

Active NC RN license

Active NC LPN/PT/OT license

Job description

Job Description

Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements. Note: This job reports to Manager, Nursing or Team Leader, Medical only.

WhatYou’llDo

• Provide clinical consultation with non-clinical staff within the Appeals Department.
• Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.
• Assist with Level 3 appeals as required.
• Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.
• Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.
• Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary.
• Initiate claim adjustments on individual cases when necessary.
• Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.
• Identify trends and high-risk issues to make recommendations to address future exposure.
• Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.
• Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
• May handle complaints/grievances as defined by the federal government.
• Coordinates with external vendors and provides requested information as requested.
• Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.

What You Bring

• Registered Nurse in the state of North Carolina
• 3 years of clinical experience
• OR Licensed Practical Nurse, Physical Therapist, Occupational Therapist,
• Licensed in the State of North Carolina and 5 years of clinical experience.

Bonus Points

• Strong attention to detail and commitment to accuracy.
• Ability to work effectively in a fast-paced, deadline-driven environment.
• Adaptability and flexibility to manage changing priorities and business needs.

WhatYou’llGet

• The opportunity to work at thecutting edgeof health care delivery with a teamthat’sdeeply invested in the community
• Work-life balance, flexibility, and the autonomy to dogreat work
• Medical, dental, and vision coverage along withnumeroushealth and wellness programs
• Parental leave and support plus adoption and surrogacyassistance
• 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.

$73,698.00 - $117,917.00

Skills

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