Clinical Appeals Analyst

🔥 18 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $73.7k - $117.9k / 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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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, and complete complex, non-routine appeals and grievances • Address customer concerns and ensure resolution and satisfaction • Ensure timeliness, quality, and efficiency in compliance with NCDOI, NCQA, legislative, and federal requirements • Provide clinical consultation to non-clinical Appeals Department staff • Coordinate the appeals process for compliance with medical necessity criteria, Corporate Medical Policy, contract provisions, and regulatory requirements • Assist with Level 3 appeals • Analyze member and provider appeals and grievances across lines of business, excluding FEP • Collect documentation from external sources including pharmaceutical companies, attorneys, and providers • Present analysis and documentation to physician committees, benefit administrators, and BCBSNC leadership • Initiate claim adjustments when necessary • Provide written case determinations to appellants and involved parties • Identify trends and high-risk issues and recommend corrective actions • Answer member and provider questions by telephone • Handle complaints and grievances as defined by the federal government • Coordinate with external vendors • Create action plans to educate internal employees about benefit misinterpretation and claim system errors • Report to Manager, Nursing or Team Leader, Medical

🎯 Requirements

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

🏖️ Benefits

• 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 • Paid Time Off (PTO) • Annual Incentive Bonus based on annual corporate goal achievement and individual performance • Flexible work arrangements and autonomy • Work-life balance