Appeals Analyst | Healthcare Regulatory & Compliance The Role: Protecting Integrity, Resolving Disputes Are you an expert in navigating the complexities of healthcare policy and regulatory compliance? We are looking for a decisive Appeals Analyst to join our team. In this role, you will act as a critical investigator, researching and resolving sensitive appeals, coding disputes, and grievances from members, providers, and regulatory agencies. You will be the bridge between clinical necessity and policy adherence, ensuring every decision is fair, documented, and compliant with state and federal mandates. Core Responsibilities In-Depth Investigation: Research and resolve confidential appeals, grievances, and coverage determinations from various stakeholders, including media outlets and senior leadership. Policy Interpretation: Analyze and explain health plan benefits, medical terminology, and coding functions to members and providers. Position Development: Prepare files and develop official position statements for external reviews performed by independent benefit panels and medical consultants. Clinical Collaboration: Gather clinical information using corporate medical criteria and partner with Medical Directors to finalize decisions on clinical appeals. Compliance Stewardship: Monitor daily reports to ensure service timeliness and strict adherence to NCDOI, CMS, ERISA, and NCQA standards. Qualifications & Requirements Education: Bachelor’s degree (or 5 years of related experience in lieu of a degree). Experience: 3+ years of related experience in healthcare appeals, grievances, or insurance operations. Skills: independent judgment, the ability to act decisively for business continuity, and awareness of the broader implications of resolution decisions. Why Join This Team? This is a high-impact role where your work directly affects business continuity and member satisfaction. You will work in a professional environment that values meticulous documentation, transparency, and clinical accuracy. Ready to apply your expertise to resolve complex healthcare challenges? Apply today! FOR MORE IMMEDIATE CONSIDERATION, email a curent resume to iris.levy@randstadusa.comsalary: $33 - $33.5 per hourshift: Firstwork hours: 8 AM - 5 PMeducation: BachelorsResponsibilities Research the grievances requests Prioritize casework, do reach outs from providers and internal teams, handle the grievance response letters. Everyday you have new work routed to you and have 30 days to action on each items. A lot of time management and case load management Analyze, research, and resolve sensitive appeals, coding disputes, and grievances from members, providers, and regulatory agencies. Interpret health plan benefits and medical terminology to explain complex decisions while exercising independent judgment according to BlueCross NC policies. Develop formal position statements for external reviews by independent organizations and medical consultants. You will document extensive investigations, monitor daily compliance reports to ensure service timeliness, and gather clinical data to partner with Medical Directors on clinical decisions. This role ensures all actions comply with mandated state and federal accreditation standards (NCQA, CMS, ERISA). Case load is always in flex. One day might be heavy, the next day might not be heavy First two weeks of training is classroom training, learing about medicare, insurance. Then job shadowing the following week to two weeks of on the job training This is a temp position, but the team will always be open to a potential conversion if the HC becomes available. Skillsmedical coding (3 years of experience is required)Medicare/Medicaid (3 years of experience is required)medical claims (3 years of experience is required)health insurance (3 years of experience is required)QualificationsYears of experience: 3 yearsExperience level: ExperiencedRandstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad. Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).This posting is open for thirty (30) days. 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