Appeals Analyst

Role Overview

The Appeals Analyst reviews, investigates, and processes appeals, coding disagreements, and grievances. The role requires careful handling of sensitive information, fast and accurate documentation, and alignment with legal, regulatory, quality, and internal policy requirements. A strong focus is placed on resolving customer issues quickly and improving customer satisfaction.

Key Responsibilities

In this position, you will independently evaluate confidential appeals, coding disputes, grievances, and coverage or organizational determinations submitted by members, member representatives, providers, media contacts, senior leaders, and regulatory bodies. You will interpret health plan benefits, policies, procedures, medical terminology, coding, and related functions for members and providers, while exercising sound judgment in line with Blue Cross NC guidelines.

You will also build case files and draft Blue Cross NC position statements for external reviews handled by independent review organizations, benefit panels, and external medical consultants. Your work will include writing thorough appeal, dispute, and grievance responses that support the final decision and meet regulatory and accreditation standards. In addition, you will maintain detailed documentation of investigations, findings, and actions across the required systems, and monitor daily reports to help ensure timeliness and compliance.

The role includes gathering clinical information using established criteria from corporate medical policies and partnering with Medical Directors, who retain responsibility for clinical appeal and grievance decisions. You must consistently deliver work that meets state, federal, accreditation, ASO performance guarantee, and BCBSNC policy requirements.

Requirements

You should have a bachelor’s degree or an advanced degree where applicable, along with 3 years of relevant experience. If you do not hold a degree, 5 years of related experience may be accepted instead. For work involving coding disputes, a Certified Professional Coder credential must be earned within 1 year of employment.

Preferred Background

Highly valued experience includes AAPC Certified Professional Coder certification, claims adjudication appeals or reimbursement work, payer or provider appeals experience, and familiarity with Medicare and/or commercial CMS guidelines. Strong analytical and critical thinking skills, excellent organization, the ability to manage competing deadlines, comfort in a fast-moving environment, and proficiency with Microsoft Office and Excel are also important.

What You Get

This role offers the chance to contribute to modern health care delivery with a team committed to the community. The organization also supports work-life balance, flexibility, and autonomy.

Benefits include medical, dental, and vision coverage, wellness programs, parental leave support, adoption and surrogacy assistance, career development opportunities, tuition reimbursement, and a 401(k) match plus an annual company contribution.

Compensation

The stated annual base salary range is $50,337 to $80,539. Pay is positioned near the middle of the range for many hires, and final compensation depends on experience, training, specialized skills, licensure, certifications, and organizational needs. The total rewards package also includes an annual incentive bonus based on company goal achievement and individual performance, paid time off, a 401(k) with employer match, and competitive health and wellness benefits.

Additional Information

Blue Cross NC states that its hiring process does not involve text-based conversations or interviews and never asks applicants to pay fees or provide financial information. Career opportunities are posted through the company’s official hiring system. Any suspected fraud should be reported to local authorities and to the company contact listed in the notice.