[Remote] Appeals Analyst

Note: The job is a remote job and is open to candidates in USA. Blue Cross NC is a healthcare organization seeking an Appeals Analyst to research, analyze, and process appeals, coding disputes, and grievances. The role involves ensuring timely and accurate documentation while adhering to regulatory requirements and organizational policies to resolve customer concerns effectively.ResponsibilitiesAnalyze, 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 guidelinesAnalyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providersRegularly 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 impactPrepare files and develops BlueCross NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultantsProvide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelinesDocument extensive investigation, relative findings, and actions in all applicable systemsAccountable for monitoring daily reports to ensure service timeliness and compliance is metGather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievancesEnsures 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)SkillsBachelor's degree or advanced degree where required3 years of related experienceIn lieu of degree, 5 years of related experienceFor coding disputes area, certified professional coder must be obtained within 1 year of employmentCertified Professional Coder through AAPC – Highly preferredHealthcare Claims adjudication appeals or reimbursement experience – Highly preferredExperience with Payor or Provider appeals – Highly PreferredKnowledge of Medicare and/or Commercial CMS guidelines - Highly PreferredStrong analytical and critical thinking abilitiesExcellent organizational skillsAbility to prioritize competing deadlinesExperience working in fast-paced environmentProficiency in Microsoft Office and ExcelBenefitsMedical, 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.Annual Incentive Bonus*Paid Time Off (PTO)Competitive health benefits and wellness programsCompany OverviewIt's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. It was founded in 1933, and is headquartered in Durham, North Carolina, USA, with a workforce of 5001-10000 employees. Its website is https://www.bluecrossnc.com/.