Clinical Appeals Analyst

BlueCross BlueShield of North Carolina • North Carolina, North Carolina • 2d ago

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.

What You'll Do

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.

Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.

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.

What You'll Bring

Registered Nurse in the state of North Carolina

3 years of clinical experence

Licensed in the State of North Carolina

What You'll Get

The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community?

Work-life balance, flexibility, and the autonomy to do great work??

Medical, 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??

Learn more (https://careers.bluecrossnc.com/global/en/benefits) ??

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

About Us

It'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. We offer more than health insurance our customers can count on. We're committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at HR.Staffing@bcbsnc.com .

For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two:

Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming

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