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Appeals Analyst, CPC Certified
Blue Cross NCPosted 10/21/2026full-timeRemote • North Carolina • United StatesMid-LevelSenior💰 $50,337 - $80,539 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in analyzing and resolving appeals, coding disputes, and grievances while ensuring compliance with regulatory standards. Proficient in interpreting health plan benefits and collaborating with Medical Directors to support clinical decisions.
Highest-signal resume keywords
Bachelor's DegreeCertified Professional Coder (CPC)3 Years Related ExperienceKnowledge of Medical TerminologyCompliance with Regulatory Standards
About the role
Key responsibilities & impact- Analyze, research, resolve, and respond to appeals, coding disputes, grievances, and coverage/organization determinations
- Interpret and explain health plan benefits, policies, procedures, medical terminology, coding, and functions to members and providers
- Exercise independent judgment and make decisions according to BlueCross NC policies and guidelines
- Prepare files and develop BlueCross NC position statements for external reviews
- Produce comprehensive responses supporting decisions and complying with regulatory and accreditation guidelines
- Document investigations, findings, and actions in applicable systems
- Monitor daily reports to ensure service timeliness and compliance
- Gather clinical information using corporate medical-policy criteria
- Partner with Medical Directors responsible for clinical appeals and grievances decisions
- Ensure work complies with NCDOI, CMS, ERISA, NCQA, ASO performance guarantees, and BCBSNC/BCBSA requirements
Requirements
What you’ll need- Bachelor’s degree or advanced degree where required, or 5 years of related experience in lieu of degree
- 3 years of related experience
- For coding disputes area, certified professional coder must be obtained within 1 year of employment
- Active AAPC Certified Professional Coder (CPC) certification is strongly preferred
- Ability to analyze, research, resolve, and respond to confidential/sensitive appeals, coding disputes, grievances, and coverage/organization determinations
- Knowledge of health plan benefits, policies, procedures, medical terminology, coding, and related functions
- Ability to comply with legislative, regulatory, accreditation, quality, and organizational standards
- Ability to gather clinical information using established criteria and work with Medical Directors
Benefits
Comp & perks- Work-life balance, flexibility, and autonomy
- Medical, dental, and vision coverage
- Health and wellness programs
- Parental leave and support
- Adoption and surrogacy assistance
- Career development programs
- Tuition reimbursement for continued education
- 401(k) match including an annual company contribution
- Annual Incentive Bonus based on annual corporate goal achievement and individual performance
- Paid Time Off (PTO)
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Appeals AnalysisCoding Dispute ResolutionHealth Plan Benefits InterpretationClinical Information GatheringDocumentation of Findings
Soft Skills
Independent JudgmentDecision MakingCommunication Skills
Tools & Technologies
Applicable Systems for DocumentationDaily Reporting Tools
Certifications & Qualifications
AAPC Certified Professional Coder (CPC)
Industry Keywords
NCDOI ComplianceCMS RegulationsERISA StandardsNCQA GuidelinesBCBSNC Requirements