Medical Review Analyst

E-Verify Program

Medical Review Analyst at Blue Cross NC determining claims eligibility and medical necessity. Utilizing clinical expertise to ensure quality, cost-effective healthcare services.

Posted 6/3/2026full-timeNorth Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $73,698 - $117,917 per yearWebsite

About the role

Key responsibilities & impact

Identify, analyze, and determine medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for claims
Ensure review and determinations meet all requirements by Regulatory and Accrediting bodies
Identify, document, and escalate system and process problems
Review physician-submitted and member-submitted claims for specified services
Issue denials according to department protocols
Maintain confidentiality of all PHI in compliance with state and federal laws
Recognize and report inappropriate billing patterns or utilization trends
Communicate with members and providers to obtain additional information
Document the required clinical information for decision-making
Perform post adjudication review of claims related to coding, billing, and reimbursement.

Requirements

What you’ll need

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
Demonstrated experience working within a health plan/insurance environment highly preferred.

Benefits

Comp & perks

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
Work-life balance, flexibility, and the autonomy to do great work

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical necessity analysisclaims reviewcodingbillingreimbursementpost adjudication reviewdocumentationproblem identificationprocess improvementconfidentiality compliance

Soft Skills

communicationanalytical thinkingattention to detailproblem-solvinginterpersonal skillsorganizational skillsescalationreportingdecision-makingconflict resolution

Certifications

RNPANPLPNNorth Carolina clinical license