RN Clinical Appeals Specialist

A client of Innova Solutions is immediately hiring for a RN Clinical Appeals Specialist

Position type: Full time Contract to hire
Duration: 3-month contract
Location: Philadelphia PA 19103 (Remote)

As a RN Clinical Appeals Specialist you will:

• Manage assigned clinical appeals from intake through resolution including case review outreach documentation gathering clinical research matched-specialty coordination determination support notification support and effectuation activities.
• Review appeal files to ensure all required documentation is complete accurate and available for review including denial letters medical records benefit information prior authorization history claims information medical policy clinical criteria provider submissions and member or authorized representative statements.
• Apply clinical nursing knowledge utilization management principles benefit language medical policy and evidence-based criteria to support appropriate case classification and appeal handling.
• Determine whether appeal issues involve medical necessity benefit coverage administrative processing pharmacy behavioral health or regulatory concerns and escalate complex or high-risk cases appropriately.
• Support Appeals Specialists in identifying the appropriate level of review matched-specialty requirements reviewer qualifications and questions for independent physician consultants or Medical Directors.
• Coordinate and document matched-specialty reviews peer review activity Medical Director review external review preparation and committee review support as required by business process and regulatory requirements.
• Review appeal investigations case summaries member and provider contacts clinical documentation and system entries to ensure accuracy completeness and compliance with internal standards.
• Prepare review and support clear written correspondence to members providers authorized representatives and other parties ensuring communications are accurate complete timely and aligned with regulatory and accreditation requirements.
• Review Level 1 and Level 2 case summaries prior to committee meetings and ensure clinical issues appeal rationale medical policy benefit provisions and reviewer questions are clearly presented.
• Serve as a clinical resource for Appeals Specialists Team Leads Supervisors Compliance Medical Directors Utilization Management Care Management Claims Provider Relations and other business areas.
• Monitor appeal inventory and case status to support compliance with applicable state federal ERISA ACA NCQA client and internal turnaround time requirements.
• Ensure appeal files are audit-ready and include documentation of the substance of the appeal investigation performed clinical and benefit review applicable criteria reviewer involvement determination rationale and required notifications.
• Support implementation of policy procedure workflow system regulatory or accreditation changes affecting clinical appeal processing.
• Identify trends documentation gaps recurring appeal issues and opportunities for process improvement quality improvement provider education or upstream utilization management feedback.
• Participate in department training calibration activities policy updates quality reviews audit preparation and continuous improvement initiatives.
• Perform all activities in accordance with corporate policies departmental procedures privacy requirements quality standards regulatory requirements and accreditation standards.

The ideal candidate will have:

• Bachelor of Science in Nursing required.
• Active unrestricted Registered Nurse license required; Pennsylvania RN license
• Minimum of five years of clinical nursing experience or equivalent healthcare experience.
• Experience in utilization management prior authorization concurrent review retrospective review case management clinical appeals grievance and appeals operations or related managed care operations.
• Demonstrated knowledge of clinical appeal processing medical necessity review benefit interpretation medical policy application and appeal documentation requirements.
• Knowledge of NCQA standards state and federal appeal regulations ERISA ACA and other regulatory or accreditation requirements applicable to appeal processing.
• Ability to review medical records clinical documentation denial rationale benefit language medical policy and utilization management criteria to support accurate appeal handling.
• Strong understanding of health plan operations including HMO PPO self-funded fully insured commercial government program or delegated vendor processes as applicable.
• Excellent written and verbal communication skills including the ability to prepare clear accurate member- and provider-facing correspondence.
• Strong analytical critical-thinking problem-solving organizational and time-management skills.
• Ability to work independently manage competing priorities meet regulatory deadlines and escalate issues appropriately.
• High attention to detail and commitment to documentation quality member advocacy regulatory compliance and audit readiness.
• Proficiency with Microsoft Office products appeal systems clinical documentation systems claims systems utilization management platforms databases and spreadsheet tools.

Preferred Qualification:

• Experience in a health plan managed care organization third-party administrator utilization management organization or delegated clinical review environment.
• Experience with NCQA accreditation audits state Department of Insurance audits internal quality audits client audits or regulatory file reviews.
• Familiarity with utilization review criteria such as InterQual MCG CMS guidance evidence-based clinical guidelines corporate medical policy and plan-specific criteria.
• Experience supporting external review independent review organization cases peer review coordination expedited appeals complex medical necessity appeals pharmacy appeals behavioral health appeals or benefit appeals.
• Knowledge of Medicare Medicaid Commercial Exchange ERISA ACA and state-specific appeal requirements.
• Experience working with Medical Directors physician consultants independent reviewers Compliance Legal Utilization Management Care Management Claims Provider Relations and Quality teams.
• Experience identifying appeal trends documentation gaps overturn drivers quality issues or process improvement opportunities.

Qualified candidates should APPLY NOW for immediate consideration!

This position is only open to applicants who can be engaged on a W-2 basis. 1099 contractors and Corp-to-Corp arrangements will not be considered for this position.

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

Gandam Meghana

PAY RANGE AND BENEFITS:
Pay Range*: $40 - $46 per hour
*Pay range offered to a successful candidate will be based on several factors including the candidates 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 50000 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 Americas 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

Website : 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 or . 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.
The company will consider for employment qualified applicants with arrest and conviction records in a manner that complies with the San Francisco Fair Chance Ordinance the Los Angeles Fair Chance Initiative for Hiring Ordinance and other applicable laws.

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Required Experience:

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