Clinical Appeals Analyst
Blue Cross Blue Shield of North Carolina - Chapel Hill, NC

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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.

  • 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. Requirements • Registered Nurse in the state of North Carolina
  • 3 years of health care industry experience preferably in
o Health insurance: Claims, Customer Service Utilization Management or Medical Review
o Clinical: Case Management, Outpatient Care, Recent Inpatient Care (within the last year), Coding, or Billing

  • Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of health care experience preferably in:
o Health insurance: Claims, Customer Service Utilization Management or Medical Review
o Clinical: Case Management, Outpatient Care, Recent Inpatient Care (within the last year), Coding, or Billing

  • Experience in word processing, preferably in Microsoft Office products. Additional Critical Skills & Knowledge Needed for Job • Experience with Blue Cross and Blue Shield of North Carolina products and systems.
  • System knowledge should include understanding and usability of MaxMC, Power MHS, Service First, Magic, Mobius, Doc Request, Medco and accessing Corporate Medical Policy.
  • Experience with of MS Word, Access, and Excel.
  • Ability to research and problem solve
  • Able to read and understand claims history, denials, payments, suspends
  • Strong Medical Knowledge
  • Ability to make concise, independent and defensible decisions in often high-pressure situations
  • Effective verbal and written communication and presentation skills
  • Excellent analytical, planning and problem-solving skills
  • Ability to successfully interface with individuals at all levels, including top management, both internal and external
  • Excellent time management skills
  • Ability to be discreet and diplomatic
  • Ability to work independently, as well as with a team
Certified Professional Coder preferred.

Blue Cross Blue Shield of North Carolina - 2 years ago - save job
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