Job Overview
Location
Remote Flex - North Carolina
Job Type
Full-time
Category
Software Engineering
Date Posted
June 3, 2026
Full Job Description
đź“‹ Description
- • Determine medical necessity, benefit eligibility, and appropriate reimbursement allowances for complex claims using clinical expertise, medical literature, records, policy guidelines, and specialized software systems.
- • Ensure all claim reviews and determinations comply with regulatory and accrediting body requirements, including federal, state, and Blue Cross and Blue Shield Association (BCBSA) standards.
- • Identify, document, and escalate system and process issues; analyze root causes and recommend actionable solutions to improve accuracy and efficiency.
- • Review physician- and member-submitted claims to assess medical necessity of treatments, applying professional criteria and referring non-conforming cases to the Medical Director with detailed clinical summaries.
- • Issue claim denials in accordance with department protocols and thoroughly document all review outcomes, clinical rationale, and referenced resources.
- • Maintain strict confidentiality of all protected health information (PHI) in full compliance with state and federal privacy laws.
- • Detect and report inappropriate billing patterns, utilization trends, or coding violations by providers; document examples for referral to Network Management or Special Investigations.
- • Communicate directly with members and providers to obtain missing information, clarify claim status, and explain determinations while documenting all interactions in medical management tools.
- • Conduct post-adjudication reviews of claims related to coding, billing, and reimbursement, specifically for FEP and Senior Market (Medicare HMO/PPO) lines of business.
- • Review Individual Business claims for potential misrepresentation, gather supporting documentation, and take appropriate internal action per company guidelines.
🎯 Requirements
- • RN, PA, or NP with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
- • LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings
- • Must hold and maintain a valid North Carolina clinical license
🏖️ Benefits
- • The opportunity to work at the cutting edge of health care delivery with a team deeply invested in the community
- • Work-life balance, flexibility, and autonomy to do great work
- • Medical, dental, and vision coverage along with numerous health and wellness programs
- • Parental leave and support plus adoption and surrogacy assistance
- • Career development programs and tuition reimbursement for continued education
- • 401k match including an annual company contribution
Skills & Technologies
About Blue Cross and Blue Shield of North Carolina
Blue Cross and Blue Shield of North Carolina is a nonprofit health insurer domiciled in North Carolina, providing medical, dental, vision, Medicare, and Medicaid coverage to individuals, employers, and government programs. Founded in 1933, the company operates the largest provider network in the state and offers telehealth, pharmacy management, wellness, and care-coordination services. Its mission is to improve health care access, affordability, and outcomes for North Carolinians while maintaining community-focused, nonprofit governance.
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