Appeals & Grievance Case Resolution Specialist

RPMGlobal; Philadelphia (Philadelphia County); Hybrid; USD 60,000 - 80,000; Full time

Benefits offered by this job

Flexible work options

Hybrid work schedules

Paid time off including holidays and$0

Health insurance coverage for you and

Job summary

AmeriHealth Caritas in Philadelphia, PA is hiring an Appeals & Grievance Case Resolution Specialist to manage the full life cycle of member and provider appeals and grievances, from intake to resolution, ensuring accuracy and regulatory compliance.

You will collaborate with Claims, Medical Management, Legal and Compliance, document all activities in the case management system, and uphold CMS, NCQA and URAC requirements while delivering timely determinations.

Qualifications

• Associate degree in Health Administration, Business, or related field preferred.
• High School Diploma/GED required.
• Knowledge of medical terminology and regulatory processes preferred.
• 2–3 years in healthcare operations, managed care, or grievances/appeals.
• Proficiency in Microsoft Office.

Responsibilities

• Manage case intake, investigation, and documentation for appeals.
• Collaborate with Claims, Medical Management, Legal, and Compliance.
• Ensure compliance with CMS, NCQA, URAC and HIPAA requirements.
• Maintain case files and timelines.

Skills

Attention to detail

Analytical skills

Customer service

Communication

Education

Associates degree in Health Admin/Business

High School Diploma/GED

Tools

Microsoft Office Suite

Job description

Appeals & Grievance Case Resolution Specialist Location Philadelphia, PA Primary Job Function Operations ID** 44984

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

The Appeals & Grievance Case Resolution Specialist is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, this role conducts case intake, investigation, and documentation to ensure accurate and timely resolution consistent with federal state, and accreditation standards. The Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements.

Essential Functions

Case Management

• Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance.
• Communicate with members, providers, or representative to clarify appeal intent and gather missing documentation including incoming calls, outgoing calls, and phone queue work as assigned.
• Prepare complete and compliant case files, ensuring all required documentation is included.
• Track case progress and maintain compliance with turnaround times and documentation standards.
• Generate accurate and timely determination and acknowledgement letters.

Investigation and Resolution

• Collaborate with internal departments such as Claims, Medical Management, Legal, and Compliance to obtain necessary information for resolution.
• Identify potential compliance issues or risk factors requiring escalation.
• Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned.
• Document all activities, correspondence, and outcomes in the case management system with attention to detail and accuracy.

Compliance & Quality

• Ensure case handling meets all application federal and state regulatory requirements, including with CMS, NCQA, and URAC.
• Maintain confidentiality and protect member information in compliance with HIPPA regulations.
• Identify opportunities for process improvements to enhance quality and efficiency.
• Serve as a resource to peers and administrators for routine case-related questions.
• Maintain professional communication with members, providers, and internal stakeholders.
• Participate in team meetings and contribute to continuous improvement initiatives.

Education/Experience

• Associate’s Degree: in Health Administration, Business, or related field preferred
• High School Diploma/GES Required

Preferred Experience Level:

• Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.
• 2 to 3 years experience in healthcare operations, managed care, or grievance/appeals coordination.

Other Skills

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.).
• Strong attention to detail and organization.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong analytical and problem-solving abilities.
• Customer service orientation with professional communication etiquette.

• Flexible work solutions including remote options
• hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement
• and more.