We’re hiring a Clinical Appeals Analyst to join the Commercial Member Appeals Team! You will be responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. You 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 Bring

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

Bonus Points (Preferred Qualifications)

Organized with strong ability to manage multiple priorities
Perform effectively under pressure; resilient in high-stress environments
Adaptable and able to pivot quickly as priorities change
Strong verbal communication skills with ability to engage members and providers
Demonstrates empathy while maintaining professionalism and composure
Ability to read, interpret, and apply medical policies and clinical criteria
Experience reviewing medical records to assess completeness and determine next steps
Strong clinical background
Proficient computer/navigation skills across multiple platforms

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

Where You’ll Work

Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused.

In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

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

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