Appeals & Grievances Specialist

Innova Solutions has a client that is immediately hiring for Appeals & Grievances Specialist

Position type: Full-time - Contract
Duration: 3 Months
Location: 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.
• 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.

The ideal candidate will have:

• 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

Preferred Skills & Qualifications:

• Experience in Utilization Management or Appeals and Grievances.

Qualified candidates should APPLY NOW for immediate consideration!


Please hit APPLY to provide the required information, and we will be back in touch as soon as possible.
We are currently interviewing to fill this and other similar positions. If this role is not a fit for you, we do offer a referral bonus program for referrals that we successfully place with our clients, subject to program guidelines.

REFERRAL PROGRAM:
This position qualifies for a Referral Bonus amount of $250-$1000 dollars. Click here to learn more - Referral Program . Please email your referral details along with their resume to View email address on click.appcast.io

Soni Kumari
View phone number on click.appcast.io
View email address on click.appcast.io

PAY RANGE AND BENEFITS:
Pay Range*: Between $25 - $29 per hour
*Pay range offered to a successful candidate will be based on several factors, including the candidate's education, work experience, work location, specific job duties, certifications, etc.

Benefits: Innova Solutions offers benefits( based on eligibility) that include the following: Medical & pharmacy coverage, Dental/vision insurance, 401(k), Health saving account (HSA) and Flexible spending account (FSA), Life Insurance, Pet Insurance, Short term and Long term Disability, Accident & Critical illness coverage, Pre-paid legal & ID theft protection, Sick time, and other types of paid leaves (as required by law), Employee Assistance Program (EAP).


ABOUT INNOVA SOLUTIONS: Founded in 1998 and headquartered in Atlanta, Georgia, Innova Solutions employs approximately 50,000 professionals worldwide and reports an annual revenue approaching $3 Billion. Through our global delivery centers across North America, Asia, and Europe, we deliver strategic technology and business transformation solutions to our clients, enabling them to operate as leaders within their fields.

Recent Recognitions:

• Named One of America's Best Employers for New Grads by Forbes (2024)
• Named One of the Best Companies to Work for by U.S. News & World Report (Private Companies List, 2024-2025)
• One of the Largest IT Staffing Firms in the US - Ranked #3 by Staffing Industry Analysts (SIA, 2024)
• One of the Largest Staffing Firms in the US - Ranked #13 by Staffing Industry Analysts (SIA, 2024; includes Innova Solutions, Volt, & HireGenics)
• Named One of the Top Ten Private Companies in Atlanta by the Atlanta Business Chronicle (2023)
• One of the Largest Certified Minority Business Enterprises (MBEs) in the United States (NMSDC, 2024)
• AWS Advanced Tier Services Partner with 100+ certifications

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Innova Solutions is an Equal Opportunity Employer and prohibits any kind of unlawful discrimination and harassment. Innova Solutions is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment on the basis of race, color, religion or belief, national origin, citizenship, social or ethnic origin, sex, age, physical or mental disability, veteran status, marital status, domestic partner status, sexual orientation, or any other status protected by the statutes, rules, and regulations in the locations where it operates. If you are an individual with a disability and need a reasonable accommodation to assist with your job search or application for employment, please contact us at View email address on click.appcast.io or View phone number on click.appcast.io. Please indicate the specifics of the assistance needed. Innova Solutions encourages all interested and qualified candidates to apply for employment opportunities. Innova Solutions (HireGenics/Volt) does not discriminate against applicants based on citizenship status, immigration status, or national origin, in accordance with 8 U.S.C. § 1324b.
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