Appeals Specialists-Hybrid

Hybrid-Appeals Specialist needed for a contract opportunity with Yoh’s client located in Philadelphia, PA.Schedule: Tuesday-Wednesday-Thursday onsite 7:30 AM-4:00 PM or 8:00 AM-4:30 PMOverviewWe’re hiring multiple Appeals Specialists to independently investigate, document, and process member and provider appeals across assigned lines of business in accordance with applicable federal/state requirements, accreditation standards, and internal policies. This role is responsible for building complete, audit-ready case files, rendering administrative determinations within delegated authority, preparing compliant correspondence, and driving timely effectuations.Key ResponsibilitiesManage assigned appeals from receipt through investigation, determination, notification, effectuation, and closure while meeting all turnaround times.Validate appeal details (request, classification, authority, timeframe, eligibility/benefits, claim/authorization history, denial rationale, and documentation).Research and reconcile discrepancies across denial letters, claims, authorizations, and case-system information; escalate misrouted/unclear cases.Interpret applicable benefits and governing documentation (EOC/SPD/benefit booklets), claims/EOBs, policies, and regulatory guidance.Build complete case files and write clear case notes, narratives, and decision rationales.Prepare external review packages when required and track outcomes.Draft and validate acknowledgment/RFI/dismissal/determination letters using approved templates and required language.Initiate and monitor effectuations/claim adjustments; track and escalate delays.Communicate with members, authorized representatives, providers, vendors, and internal partners by phone and in writing.Manage daily inventory, prioritize expedited/aging cases, and meet quality/timeliness expectations.QualificationsBachelor’s degree in healthcare administration, business, population health, or related field.3+ years of healthcare operations experience required.Medicare experienceUtilization Management or Appeals/Grievances experience preferred.Working knowledge of plan products, benefits, and claims procedures.Strong research, documentation, and written communication skills.Ability to handle complex issues and collaborate cross-functionally.Must have your own laptop and monitorEstimated Min Rate: $30.00Estimated Max Rate: $30.00What’s In It for You?We welcome you to be a part of the largest and legendary global staffing companies to meet your career aspirations. Yoh’s network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities and gain access to this exclusive opportunity available to you. Benefit eligibility is in accordance with applicable laws and client requirements. Benefits include:Medical, Prescription, Dental & Vision Benefits (for employees working 20+ hours per week)Health Savings Account (HSA) (for employees working 20+ hours per week)Life & Disability Insurance (for employees working 20+ hours per week)MetLife Voluntary BenefitsEmployee Assistance Program (EAP)401K Retirement Savings PlanDirect Deposit & weekly epayrollReferral Bonus ProgramsCertification and training opportunitiesNote: Any pay ranges displayed are estimations. Actual pay is determined by an applicant's experience, technical expertise, and other qualifications as listed in the job description. All qualified applicants are welcome to apply.Yoh, a Day & Zimmermann company, is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.Visit to contact us if you are an individual with a disability and require accommodation in the application process.For California applicants, qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. All of the material job duties described in this posting are job duties for which a criminal history may have a direct, adverse, and negative relationship potentially resulting in the withdrawal of a conditional offer of employment.It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.By applying and submitting your resume, you authorize Yoh to review and reformat your resume to meet Yoh’s hiring clients’ preferences. To learn more about Yoh’s privacy practices, please see our Candidate Privacy Notice: Safe During Your Job SearchFraudulent recruiting communications have become increasingly common. Emails from Yoh recruiters will only come from an @yoh.com email address. Yoh will never ask candidates to pay fees, purchase equipment, send gift cards, or transfer funds as part of the recruiting or hiring process. If you receive a communication that appears suspicious or requests payment, contact Yoh directly before responding or sharing personal information.Reference: BH-400896