Appeals & Grievances Specialist

Innova Solutions•Philadelphia, PA

17h•Onsite

About The Position

A client of Innova Solutions is immediately hiring for an Appeals & Grievances Specialist. This is a Contract to Hire position with a duration of 03 Months, located in Philadelphia, PA. As an Appeals & Grievances Specialist, you will manage assigned appeals from case receipt through investigation, determination, notification, effectuation, and closure while meeting all regulatory and internal turnaround times. You will accurately identify the substance of the appeal and reconcile discrepancies among the appeal request, denial letter, claim, authorization, and case-system information. You will also escalate unclear or incorrectly routed cases before compliance is affected. The investigation of the appellant argument involves interpreting applicable member benefits, Evidence of Coverage, benefit booklets, Summary Plan Descriptions, claims history, Explanation of Benefits, authorization records, denial rationale, medical and claim-payment policies, CMS guidance, state requirements, and operational reference materials. You will prepare complete external-review packages, submit them through the designated process within required timeframes, monitor for determinations, and document the outcome and follow-up actions. Additionally, you will draft and validate acknowledgment, request-for-information, dismissal, and determination correspondence using the correct approved template, addressee, appeal rights, timeframe, rationale, benefit or policy reference, and required regulatory language. You will initiate overturned-case effectuation or claim-adjustment requests, monitor completion, reconcile outstanding tasks and ticklers, and escalate delays that present member, financial, quality, or compliance risk. Finally, you will use appeal and supporting systems effectively, including the case-management system, claims and eligibility platforms, authorization systems, document repositories, communication tools, policy libraries, and applicable vendors or external-review portals.

Requirements

Bachelor’s degree in healthcare administration, business, population health or related field.
Minimum of 3 years working in healthcare operations.
Knowledge of plan products, benefits, and claims procedures.

Nice To Haves

Experience in Utilization Management or Appeals and Grievances.

Responsibilities

Manage assigned appeals from case receipt through investigation, determination, notification, effectuation, and closure while meeting all regulatory and internal turnaround times.
Accurately identify the substance of the appeal and reconcile discrepancies among the appeal request, denial letter, claim, authorization, and case-system information.
Escalate unclear or incorrectly routed cases before compliance is affected.
Investigate the appellant argument by interpreting applicable member benefits, Evidence of Coverage, benefit booklets, Summary Plan Descriptions, claims history, Explanation of Benefits, authorization records, denial rationale, medical and claim-payment policies, CMS guidance, state requirements, operational reference materials.
Prepare complete external-review packages, submit them through the designated process within required timeframes, monitor for determinations, and document the outcome and follow-up actions.
Draft and validate acknowledgment, request-for-information, dismissal, and determination correspondence using the correct approved template, addressee, appeal rights, timeframe, rationale, benefit or policy reference, and required regulatory language.
Initiate overturned-case effectuation or claim-adjustment requests, monitor completion, reconcile outstanding tasks and ticklers, and escalate delays that present member, financial, quality, or compliance risk.
Use appeal and supporting systems effectively, including the case-management system, claims and eligibility platforms, authorization systems, document repositories, communication tools, policy libraries, and applicable vendors or external-review portals.