Commercial Appeals Specialist

The Judge Group; Philadelphia (Philadelphia County); Híbrido; USD 33 000 - 47 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical, dental, and vision insurance

Hybrid work arrangement (onsite Tue-Th

Resumo da oferta

The Judge Group is seeking a Commercial Appeals Specialist for a hybrid contract role in the tri-state area. You will independently investigate, document, and process member and provider appeals in accordance with internal policies and regulatory requirements.

You will validate appeal requests, classifications, and supporting documentation, build audit-ready case files, and draft determination letters within delegated authority. Collaboration with internal partners is essential.

Qualificações

• Bachelor’s degree in Healthcare Administration, Business, Population Health, or related field.
• Minimum of 3 years of experience in healthcare operations.
• Must reside in PA, NJ, or DE tri-state area and commute onsite Tue-Thu.

Responsabilidades

• Manage assigned commercial appeals from receipt through investigation, determination, notification, effectuation, and closure within regulatory timelines.
• Validate case accuracy using policies applicable to the member’s benefit plan.
• Prepare audit-ready case files with notes, narratives, and determinations.
• Draft and validate correspondence and determination letters with correct templates and timelines.

Conhecimentos

Case management

Documentation

Regulatory knowledge

Communication

Attention to detail

Formação académica

Bachelor’s degree in Healthcare Administration

Ferramentas

Case management systems

Claims systems

Authorization systems

Descrição da oferta de emprego

• Position Type: Contract (Hybrid)
• Start Date: November 2, 2026
• End Date: March 6, 2027
• Pay Rate: Up to $29.50/hr (37.5-hour workweek)
• Location & Onsite Requirement: Hybrid – Onsite 3 days/week (Tuesday, Wednesday, and Thursday). Candidates must reside in the tri-state area (PA, NJ, or DE).
• Equipment Requirements: Personal laptop required; external monitor preferred.
• Interview Process: Two 30-minute virtual interviews via Microsoft Teams.

Role Overview

• Position Type: Contract (Hybrid)
• Start Date: November 2, 2026
• End Date: March 6, 2027
• Pay Rate: Up to $29.50/hr (37.5-hour workweek)
• Location & Onsite Requirement: Hybrid – Onsite 3 days/week (Tuesday, Wednesday, and Thursday). Candidates must reside in the tri-state area (PA, NJ, or DE).
• Equipment Requirements: Personal laptop required; external monitor preferred.
• Interview Process: Two 30-minute virtual interviews via Microsoft Teams.

Position Summary

The Commercial Appeals Specialist independently investigates, documents, and processes member and provider appeals across assigned commercial lines of business in accordance with internal policies and procedures, as well as applicable federal, state, contractual, and accreditation requirements.

In this role, you will validate appeal requests, classifications, appellant authority, regulatory timeframes, member eligibility, benefits, claims, authorization histories, denial rationales, and supporting clinical documentation. The Specialist builds complete, audit-ready case files, evaluates appellant arguments against coverage policies, renders administrative determinations within delegated authority, or routes complex cases to designated teams.

Additionally, you will draft accurate, compliant determination letters, initiate required effectuations, and manage end-to-end case activities within strict quality and timeliness standards.

Key Responsibilities & Duties

Case Management & Investigation

• Manage assigned commercial appeals from receipt through investigation, determination, notification, effectuation, and closure while adhering to all regulatory and internal turnaround times.
• Validate case accuracy using appropriate policies and procedures applicable to the member’s specific benefit plan.
• Reconcile discrepancies among appeal requests, denial letters, claims, authorizations, and system records; elevate unclear or misrouted cases prior to compliance impacts.
• Investigate appellant arguments by interpreting member benefits, Evidence of Coverage (EOC), Summary Plan Descriptions (SPD), claims histories, Explanation of Benefits (EOB), authorization records, denial rationales, medical/payment policies, CMS guidance, and state requirements.

Documentation & Compliance

• Build complete, audit-ready case files in accordance with organizational documentation standards.
• Prepare clear case notes, claim summaries, case narratives, and decision rationales that detail the issue, research conducted, evidence reviewed, policy provisions applied, determination, and next steps.
• Draft and validate correspondence (acknowledgments, requests for information, dismissals, and determination letters) using correct templates, appeal rights, timeframes, and regulatory language.
• Prepare complete external-review packages, submit them via designated processes within required timeframes, monitor outcomes, and document follow-up actions.

Operations, Claims & Collaboration

• Initiate overturned-case effectuations or claim-adjustment requests; monitor completion, reconcile outstanding tasks, and elevate delays that present compliance, financial, or member risk.
• Communicate professionally with members, authorized representatives, providers, vendors, and internal business partners via phone and written correspondence.
• Effectively navigate internal systems, including case management platforms, claims/eligibility engines, authorization systems, document repositories, and policy libraries.
• Manage daily inventory, prioritize expedited and aging cases, track work at risk, and promptly elevate operational or system barriers.

Qualifications & Requirements

Minimum Qualifications

• Education: Bachelor’s degree in Healthcare Administration, Business, Population Health, or a related field.
• Experience: Minimum of 3 years of experience working in healthcare operations.
• Location: Must reside in the PA, NJ, or DE tri-state area and be able to commute onsite Tuesday through Thursday.

Preferred Qualifications

• Background in Utilization Management (UM) or Appeals & Grievances (A&G).
• Working knowledge of commercial plan products, benefit structures, and claim-adjudication procedures.
• Demonstrated experience researching complex clinical, regulatory, or benefit coverage issues.

Skills & Competencies

• Strong writing, editing, proofreading, and case-narrative drafting skills.
• Excellent customer service, organizational, time management, and problem-solving skills.
• Ability to collaborate effectively across internal departments and external partners.

Comprehensive Benefits:

Health coverage available for eligible candidates, including Medical, Dental, and Vision insurance.

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.