Appeals Analyst (Remote) Position Available In Wake, North Carolina

Appeals Analyst (Remote) 4.4 4.4 out of 5 stars Raleigh, NC • Remote Piper Companies is seeking a Appeals Analyst to work remotely for a highly accredited health insurance organization to complete the analysis, review, and submission of complex appeals. Responsibilities of the

Appeals Analyst:

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 policies and guidelines. Acts decisively to ensure business continuity and with awareness of all possible implications and impact. Prepare files and develops 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 company policies and procedures. Qualifications of the

Appeals Analyst:

Bachelor’s degree or advanced degree where required. 3 years of related experience In lieu of degree, 5 years of related experience CPC required Must be in approved states of NC (preferred), AL, AZ, AR, CO, FL, GA, ID, IN, IA, KS, KY, LA, MD, MI, MS, MO, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI & WY Compensation for the

Appeals Analyst:

Salary Range:

$24 – 28/hr based on relative experience Comprehensive Benefits including Medical, Dental, Vision, 401k, PTO, Sick Leave if required by law, & Holidays This job opens for applications on 5/7/2025. Applications for this job will be accepted for at least 30 days from the posting date.

Keywords:

Clinical Appeals Analyst, health insurance, RN, LPN, NC, EMR, NCDOI, NCQA, pharmaceutical companies, health care, complex appeals, claims, analysis, research #LI-PB2 #LI-REMOTE