Appeals Specialists-Hybrid

Yoh,-A-Day-; Philadelphia (Philadelphia County); Hybrid; USD 34,000 - 49,000; Full time

Benefits offered by this job

Medical, Prescription, Dental & Vision

Health Savings Account

401K Retirement Savings Plan

Direct Deposit & weekly epayroll

Certification and training

Job summary

Yoh, a Day & Zimmermann company, seeks multiple Appeals Specialists in Philadelphia to independently investigate, document, and process member and provider appeals across lines of business. Build audit-ready case files, render determinations, and prepare compliant correspondence within delegated authority.

Role requires 3+ years in healthcare operations and Medicare experience; Utilization Management/Appeals experience is preferred.

Qualifications

• Bachelor’s degree required.
• 3+ years of healthcare operations experience.
• Medicare experience required.
• Utilization Management or Appeals/Grievances experience preferred.
• Knowledge of plan products, benefits and claims procedures.
• Ability to handle complex issues and collaborate cross-functionally.

Responsibilities

• Manage assigned appeals from receipt through investigation, determination, notification, effectuation, and closure.
• Validate appeal details (request, classification, authority, timeframe, eligibility/benefits, claim/authorization history, denial rationale).
• Research and reconcile discrepancies across denial letters, claims, authorizations, and case-system information.
• Interpret 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.
• Initiate and monitor effectuations/claim adjustments; track and elevate delays.
• Communicate with members, authorized representatives, providers, vendors, and internal partners by phone and in writing.

Skills

Research skills

Written communication

Cross-functional collaboration

Documentation

Own laptop and monitor

Education

Bachelor’s degree in healthcare administration, business, population health, or related field

Job description

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 PM

Overview

We’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 Responsibilities

• Manage 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; elevate 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 elevate 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.

Qualifications

• Bachelor’s degree in healthcare administration, business, population health, or related field.
• 3+ years of healthcare operations experience required.
• Medicare experience
• Utilization 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 monitor

Estimated Min Rate: $30.00

Estimated Max Rate: $30.00

What’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 Benefits
• Employee Assistance Program (EAP)
• 401K Retirement Savings Plan
• Direct Deposit & weekly epayroll
• Referral Bonus Programs
• Certification and training opportunities

Note: 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.

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.

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.

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