Clinical Appeals Analyst

Job Description

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

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.

Skills