Team Leader, Appeals at Blue Cross and Blue Shield of North Carolina in Durham, North Carolina

Job Description:

The majority of our roles will continue working from home through September. Once campus restrictions begin easing in October, we will continue to encourage employees to take a virtual-first approach to their work when possible. As long as job responsibilities are not impacted, being in the office full-time will not be necessary or expected. During the interview process, our Talent Advisors will walk through our virtual-first approach and will answer questions you may have.

Additional Locations:

Telework - North Carolina

Job Description

Driven by the importance of their work, our team members innovate to elevate. We're encouraged to be curious, collaborate, think outside the box and turn ideas into solutions that transform health care.

As the leader of this team you'll supervise the formal grievance process to ensure the resolution of grievances and appeals consistent with organizational policies and procedures and which are compliant with state and federal guidelines. Additionally, you will oversee the daily operations and case-load assignments and priorities.

If you are ready to make a career out of making a difference in a dynamic department, then you are the person for this team.

What You Will Be Doing:

• Supervise staff within the appeals department.


• Take action, make decisions, and shape team or group priorities to reflect the organization's core competencies. Guide and motivate others to take appropriate actions.


• Take action, make decisions, and shape team or group priorities to meet departmental goals and regulatory standards.


• Consult with appropriate staff in preparation of Appeals Committee and panel meetings.


• Handle and /or direct the handling of difficult customer calls regarding appeals or quality issues.


• Work with staff to produce efficient and effective workflows and processes. Advise and instruct staff on meeting appeals goals and policies. Instruct staff in communication to providers and members regarding decisions and supporting rationale.


• Evaluate data requests to ensure data requirements are being met. Assist staff employees and management with their information needs.


• Responsible for all related ad hoc reporting and assigned projects/interventions


• Work with management to continuously improve operations, resolve cross-team issues, and allocate resources across the department and other divisions, as needed.

What You Bring:

• Bachelor's degree and a minimum of 4 years of managed care experience in health insurance: Claims, Customer Service, Utilization Management, or Medical Review


• If no degree, a minimum of 6 years of managed care experience in Health insurance: Claims, Customer Service, Utilization Management, or Medical Review


• 3 years of direct supervisory experience or 3 years of solid demonstration of leadership skills (i.e. training, mentoring, coaching, etc.).

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