Commercial Appeals Specialist

Alpha Business Solutions LLC; Philadelphia (Philadelphia County); Hybrid; USD 34,000 - 48,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Job summary

Alpha Business Solutions LLC in Philadelphia, PA is seeking a Commercial Appeals Specialist for a hybrid role (onsite 3x/week Tue-Thu). The contract-to-hire position requires investigating, documenting, and processing member and provider appeals across lines of business in line with policies and regulations.

You will build audit-ready case files, draft determinations, and communicate with members, providers, and internal teams.

Qualifications

• Bachelor’s degree in healthcare administration, business, population health or related field.
• Experience in appeals, denials, or health insurance processes preferred.
• Strong analytical and documentation skills.
• Excellent written and verbal communication.

Responsibilities

• Manage appeals from receipt through investigation and closure.
• Validate case accuracy against policies and member benefits.
• Identify issues and reconcile discrepancies across records.
• Interpret benefits, EOC, and other policy documents.
• Build audit-ready case files and write determinations.
• Draft notification letters with regulatory language.
• Coordinate with internal teams and external providers as needed.
• Maintain daily inventory, meet productivity/quality standards.

Skills

Investigation

Case management

Communication skills

Regulatory knowledge

Education

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

Job description

Job Description

Job Description

Job Title: Commercial Appeals Specialist

Location: Hybrid role - Philadelphia, PA 19103 - Onsite 3x/week Tues-Thurs

Duration: Contract-to-Hire | 3 months

Pay rate: $29.50/HR W2

Laptop required, monitor preferred.

Job Category: Insurance Professional & Clinical

Summary

The Appeals Specialist independently investigates, documents, and processes member and provider appeals across assigned lines of business in accordance with client’s policies and procedures and applicable federal, state, contractual, and accreditation requirements. The Specialist validates the appeal request, classification, appellant authority, regulatory timeframe, member eligibility, benefits, claims, authorization history, denial rationale, and supporting documentation. The Appeal Specialist is responsible for building a complete and audit-ready case file, investigating the appellant argument inclusive of application of the correct benefit, policy, and procedural requirements. The Appeal Specialist renders administrative determinations within delegated authority or routes cases to the correct team for review and determination. The Appeal Specialist is responsible for creating accurate, compliant determination letters, initiating and monitoring required effectuations, and completing all case activities within established quality and timeliness standards.

Responsibilities

• 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 an 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, and operational reference materials.
• 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 for 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 elevate 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 elevate system, access, documentation, workload, or process barriers.
• Perform other duties as assigned.

Education:

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

Thank you, Ashu

Benefits

• Medical for full time employees
• Dental, and Vision Insurance
• Life Insurance, Short-Term Disability, Long-Term Disability, etc.

Company Description

Hiring for a client who are a large insurance company. This is Contract to Hire.

Company Description

Hiring for a client who are a large insurance company. This is Contract to Hire.