Appeals Analyst, CPC Certified
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Job Description
Appeals Analyst researching healthcare appeals, coding disputes, and grievances for Blue Cross NC. Ensuring compliant decisions, documentation, and timely member resolution.
Responsibilities:
- Analyze, research, resolve, and respond to appeals, coding disputes, grievances, and coverage/organization determinations
- Interpret and explain health plan benefits, policies, procedures, medical terminology, coding, and functions to members and providers
- Exercise independent judgment and make decisions according to BlueCross NC policies and guidelines
- Prepare files and develop BlueCross NC position statements for external reviews
- Produce comprehensive responses supporting decisions and complying with regulatory and accreditation guidelines
- Document investigations, findings, and actions in applicable systems
- Monitor daily reports to ensure service timeliness and compliance
- Gather clinical information using corporate medical-policy criteria
- Partner with Medical Directors responsible for clinical appeals and grievances decisions
- Ensure work complies with NCDOI, CMS, ERISA, NCQA, ASO performance guarantees, and BCBSNC/BCBSA requirements
Requirements:
- Bachelor’s degree or advanced degree where required, or 5 years of related experience in lieu of degree
- 3 years of related experience
- For coding disputes area, certified professional coder must be obtained within 1 year of employment
- Active AAPC Certified Professional Coder (CPC) certification is strongly preferred
- Ability to analyze, research, resolve, and respond to confidential/sensitive appeals, coding disputes, grievances, and coverage/organization determinations
- Knowledge of health plan benefits, policies, procedures, medical terminology, coding, and related functions
- Ability to comply with legislative, regulatory, accreditation, quality, and organizational standards
- Ability to gather clinical information using established criteria and work with Medical Directors
Benefits:
- Work-life balance, flexibility, and autonomy
- Medical, dental, and vision coverage
- Health and wellness programs
- Parental leave and support
- Adoption and surrogacy assistance
- Career development programs
- Tuition reimbursement for continued education
- 401(k) match including an annual company contribution
- Annual Incentive Bonus based on annual corporate goal achievement and individual performance
- Paid Time Off (PTO)
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