Appeals Analyst Position Available In Durham, North Carolina
Tallo's Job Summary: The Appeals Analyst position, located in Durham, NC, offers a fully remote opportunity in 28 states. This 1-year contract-to-hire role requires CPC certification and experience in analyzing, researching, and responding to appeals and coding disputes. Responsibilities include interpreting health plan benefits, preparing position statements, and ensuring compliance with regulatory guidelines. A Bachelor's degree and 3 years of related experience are required. Mindlance is the hiring organization.
Job Description
Appeals Analyst#25-58176
Durham, NC
Fully Remote Job Description 100% Remote in the 28 states – North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely. Manager Notes
1 year contract to hire.
Interview process – 1 interview with 2 to 3 managers
MUST BE CPC
(CERTIFIED
PROFESSIONAL CODING
)
CERTIFIED
Care Radius a plus
Facets a plus
Coding is not required
Additional Skills:
Able to work with a large team (about 29 others).
Desk management and organizational skills
Responsibilities:
Analyze, research, resolve and respond to confidential/sensitive appeals, coding disputes, grievances and coverage/organization determinations from members, member’s representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines. Analyze, interpret, and explain health plan benefits, policies, procedures, medical terminology, coding and functions to members and/or providers. Regularly and independently exercise judgement to make appropriate decisions based on Client NC policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact. Prepare files and develops Client NC position statements for external reviews performed by independent review organizations, benefit panels and external medical consultants. Provide comprehensive appeals, coding disputes and grievances responses that support the decision and comply with regulatory and accreditation guidelines. Document extensive investigation, relative findings, and actions in all applicable systems Accountable for monitoring daily reports to ensure service timeliness and compliance is met. Gather clinical information by using established criteria provided in corporate medical policies; partner with Medical Directors who are responsible for all decisions regarding clinical appeals/grievances. Ensures timeliness, quality, and efficiency in all work to comply with applicable mandated State (NCDOI) and/or Federal (Centers for Medicare & Medicaid Services (CMS), ERISA, etc.) accreditation agency standards (National Committee for Quality Assurance – NCQA), ASO group performance guarantees and BCBSNC policies and procedures (to include BCBSA requirements).
Hiring Requirements:
Bachelor’s degree or advanced degree where required.
3 years of related experience
In lieu of degree, 5 years of related experience
CPC required
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
