Appeals Analyst, CPC Certified

🔥 9 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $50.3k - $80.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Blue Cross NC

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross NC is a health insurance provider that offers a range of health plans and services to individuals and groups. The company focuses on delivering quality healthcare coverage and improving health outcomes for its members through innovative health programs and services. Blue Cross NC is committed to enhancing access to affordable healthcare while supporting the health and wellness of the communities it serves.

📋 Description

• 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)