Available Positions

Clinical Appeals Analyst at Pharmaceutical Company in Durham, North Carolina, United States —

  • Pharmaceutical
  • Pharmaceutical Company
  • Durham, North Carolina, United States
  • 1/28/20

Job ID: 136132

Job Description

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. 

•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 


•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 


•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. 

•lMay handle complaints/grievances as defined by the federal government. 



• Required Skills: Registered Nurse in the state of North Carolina 

• 3-5 years of clinical experience; OR 

• Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of 

clinical experience. 

• Professional, punctual, attendance everyday. 

• 100% onsite, Remote is not an option 


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