Appeals & Grievances Specialist

Innova Solutions•Philadelphia, PA

22h•Onsite

About The Position

Innova Solutions has a client that is immediately hiring for an Appeals & Grievances Specialist. This is a full-time, contract position for 3 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 validate the accuracy of cases assigned using the appropriate policies and procedures applicable to the member’s benefit plan. 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, and state requirements. Build a complete case file to support the investigation and determination of the appeal in accordance with documentation standards. Prepare clear case notes, claim summaries, case narratives, and decision rationales that accurately explain the issue, research performed, evidence reviewed, applicable benefit or policy provisions, determination, and required next steps. Prepare complete external-review packages, submit them through the designated process within required timeframes, monitor determinations, and document the outcome and follow-up actions. Communicate professionally with members, authorized representatives, providers, vendors, and internal business partners by telephone and in writing; conduct required outreach; and document each communication accurately in the appropriate system. 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 vendor or external-review portals. Manage daily inventory, prioritize expedited and aging cases, identify work at risk, meet productivity and quality expectations, and promptly escalate system, access, documentation, workload, or process barriers.

Requirements

A bachelor’s degree in healthcare administration, business, population health or related field.
Minimum of 3 years working in healthcare operations.
Working knowledge of plan products, benefits, and claims procedures.
Demonstrated ability to research and handle complex issues.
Ability to collaborate with a variety of individuals both internally and externally.
Writing, editing, and proofreading skills.
Excellent customer service, organizational, time management and communication skills.

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.
Validate accuracy of cases assigned using the appropriate policies and procedures applicable to the member’s benefit plan.
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.
Build a complete case file to support the investigation and determination of the appeal in accordance with documentation standards.
Prepare clear case notes, claim summaries, case narratives, and decision rationales that accurately explain the issue, research performed, evidence reviewed, applicable benefit or policy provisions, determination, and required next steps.
Prepare complete external-review packages, submit them through the designated process within required timeframes, monitor determinations, and document the outcome and follow-up actions.
Communicate professionally with members, authorized representatives, providers, vendors, and internal business partners by telephone and in writing; conduct required outreach; and document each communication accurately in the appropriate system.
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 vendor or external-review portals.
Manage daily inventory, prioritize expedited and aging cases, identify work at risk, meet productivity and quality expectations, and promptly escalate system, access, documentation, workload, or process barriers.