Blue Cross NC · 1 day ago
Clinical Appeals Analyst
United States
Full-time
Remote
Mid Level
$74K/yr - $118K/yr
3+ years expBlue Cross NC is a healthcare organization seeking a Clinical Appeals Analyst to manage complex appeals and grievances. The role involves ensuring compliance with various healthcare regulations and providing clinical consultation while coordinating the appeals process.
Financial ServicesHealth InsuranceInsurance
Responsibilities
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
Qualification
Required
Registered Nurse in the state of North Carolina
3 years of clinical experience
Licensed in the State of North Carolina
Benefits
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
Company
Blue Cross NC
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.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Tunde Sotunde
President and Chief Executive Officer
Caleb Davies
Medicaid Market CFO - Healthy Blue of NC Medicaid
Recent News
2026-01-06
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