RN Clinical Appeals Specialist

Innova Solutions Inc; Philadelphia (Philadelphia County); À distance; USD 55 000 - 63 000; Plein temps

Avantages offerts par ce poste

Medical & pharmacy coverage

Dental/vision insurance

401(k)

HSA and FSA

Life Insurance

Disability insurance

Pre-paid legal & ID theft protection

Sick time and paid leaves

Résumé du poste

Innova Solutions is hiring an RN Clinical Appeals Specialist in Philadelphia, PA. The role is a 3-month contract-to-hire, full-time, with remote options. You will manage appeals, review documentation, apply criteria, and coordinate complex reviews with Medical Directors and consultants.

The position requires a PA RN license, a BSN, and 5+ years in clinical nursing or related managed care operations. W‑2 only; benefits apply.

Qualifications

• RN license (PA) and BSN required.

Responsabilités

• Manage assigned clinical appeals through intake to resolution.

Connaissances

Clinical appeals

Utilization management

Analytical thinking

Communication skills

Time management

Formation

Bachelor of Science in Nursing

Outils

MS Office

Appeal systems

Clinical documentation systems

Claims systems

UM platforms

Databases

Spreadsheets

Description du poste

A client of Innova Solutions is immediately hiring for a RN Clinical Appeals Specialist.

Position type: Full time - Contract to hire

Duration: 3-month contract

Location: Philadelphia, PA 19103 (Remote)

Responsibilities

• Manage assigned clinical appeals from intake through resolution, including case review, outreach, documentation gathering, clinical research, matched-specialty coordination, determination support, notification support, and effectuation activities.
• Review appeal files to ensure all required documentation is complete, accurate, and available for review, including denial letters, medical records, benefit information, prior authorization history, claims information, medical policy, clinical criteria, provider submissions, and member or authorized representative statements.
• Apply clinical nursing knowledge, utilization management principles, benefit language, medical policy, and evidence-based criteria to support appropriate case classification and appeal handling.
• Determine whether appeal issues involve medical necessity, benefit coverage, administrative processing, pharmacy, behavioral health, or regulatory concerns, and advance complex or high-risk cases appropriately.
• Support Appeals Specialists in identifying the appropriate level of review, matched-specialty requirements, reviewer qualifications, and questions for independent physician consultants or Medical Directors.
• Coordinate and document matched-specialty reviews, peer review activity, Medical Director review, external review preparation, and committee review support as required by business processes and regulatory requirements.
• Review appeal investigations, case summaries, member and provider contacts, clinical documentation, and system entries to ensure accuracy, completeness, and compliance with internal standards.
• Prepare, review, and support clear written correspondence to members, providers, authorized representatives, and other parties, ensuring communications are accurate, complete, timely, and aligned with regulatory and accreditation requirements.
• Review Level 1 and Level 2 case summaries prior to committee meetings and ensure clinical issues, appeal rationale, medical policy, benefit provisions, and reviewer questions are clearly presented.
• Serve as a clinical resource for Appeals Specialists, Team Leads, Supervisors, Compliance, Medical Directors, Utilization Management, Care Management, Claims, Provider Relations, and other business areas.
• Monitor appeal inventory and case status to support compliance with applicable state, federal, ERISA, ACA, NCQA, client, and internal turnaround‑time requirements.
• Ensure appeal files are audit‑ready and include documentation of the substance of the appeal, investigation performed, clinical and benefit review, applicable criteria, reviewer involvement, determination rationale, and required notifications.
• Support implementation of policy, procedure, workflow, system, regulatory, or accreditation changes affecting clinical appeal processing.
• Identify trends, documentation gaps, recurring appeal issues, and opportunities for process improvement, quality improvement, provider education, or upstream utilization management feedback.
• Participate in department training, calibration activities, policy updates, quality reviews, audit preparation, and continuous improvement initiatives.
• Perform all activities in accordance with corporate policies, departmental procedures, privacy requirements, quality standards, regulatory requirements, and accreditation standards.

Qualifications

• Bachelor of Science in Nursing required.
• Active, unrestricted Registered Nurse license required; Pennsylvania RN license.
• Minimum of five years of clinical nursing experience or equivalent healthcare experience.
• Experience in utilization management, prior authorization, concurrent review, retrospective review, case management, clinical appeals, grievance and appeals operations, or related managed care operations.
• Demonstrated knowledge of clinical appeal processing, medical necessity review, benefit interpretation, medical policy application, and appeal documentation requirements.
• Knowledge of NCQA standards, state and federal appeal regulations, ERISA, ACA, and other regulatory or accreditation requirements applicable to appeal processing.
• Ability to review medical records, clinical documentation, denial rationale, benefit language, medical policy, and utilization management criteria to support accurate appeal handling.
• Strong understanding of health plan operations, including HMO, PPO, self-fund, fully insured, commercial, government program, or delegated vendor processes, as applicable.
• Excellent written and verbal communication skills, including the ability to prepare clear, accurate, member- and provider-facing correspondence.
• Strong analytical, critical-thinking, problem-solving, organizational, and time-management skills.
• Ability to work independently, manage competing priorities, meet regulatory deadlines, and elevate issues appropriately.
• High attention to detail and commitment to documentation quality, member advocacy, regulatory compliance, and audit readiness.
• Proficiency with Microsoft Office products, appeal systems, clinical documentation systems, claims systems, utilization management platforms, databases, and spreadsheet tools.

Preferred Qualifications

• Experience in a health plan, managed care organization, third-party administrator, utilization management organization, or delegated clinical review environment.
• Experience with NCQA accreditation audits, state Department of Insurance audits, internal quality audits, client audits, or regulatory file reviews.
• Familiarity with utilization review criteria such as InterQual, MCG, CMS guidance, evidence-based clinical guidelines, corporate medical policy, and plan-specific criteria.
• Experience supporting external review, independent review organization cases, peer review coordination, expedited appeals, complex medical necessity appeals, pharmacy appeals, behavioral health appeals, or benefit appeals.
• Knowledge of Medicare, Medicaid, Commercial Exchange, ERISA, ACA, and state-specific appeal requirements.
• Experience working with Medical Directors, physician consultants, independent reviewers, Compliance, Legal, Utilization Management, Care Management, Claims, Provider Relations, and Quality teams.
• Experience identifying appeal trends, documentation gaps, overturn drivers, quality issues, or process improvement opportunities.

W‑2: This position is only open to applicants who can be engaged on a W‑2 basis. 1099 contractors and Corp‑to‑Corp arrangements will not be considered for this position.

Pay Range and Benefits

Pay Range: $40 - $46 per hour

Pay range offered to a successful candidate will be based on several factors, including the candidate's education, work experience, work location, specific job duties, certifications, etc.

Benefits: Innova Solutions offers benefits (based on eligibility) that include the following:

• Medical & pharmacy coverage
• Dental/vision insurance
• 401(k)
• Health saving account (HSA) and Flexible spending account (FSA)
• Life Insurance
• Pet Insurance
• Short term and Long term Disability
• Accident & Critical illness coverage
• Pre-paid legal & ID theft protection
• Sick time, and other types of paid leaves (as required by law)
• Employee Assistance Program (EAP)

About Innova Solutions

Founded in 1998 and headquartered in Atlanta, Georgia, Innova Solutions employs approximately 50,000 professionals worldwide and reports an annual revenue approaching $3 Billion. Through our global delivery centers across North America, Asia, and Europe, we deliver strategic technology and business transformation solutions to our clients, enabling them to operate as leaders within their fields.

Recent Recognitions

Named One of America's Best Employers for New Grads by Forbes (2024)
Named One of the Best Companies to Work for by U.S. News & World Report (Private Companies List, 2024-2025)
One of the Largest IT Staffing Firms in the US - Ranked #3 by Staffing Industry Analysts (SIA, 2024)
One of the Largest Staffing Firms in the US - Ranked #13 by Staffing Industry Analysts (SIA, 2024; includes Innova Solutions, Volt, & HireGenics)
Named One of the Top Ten Private Companies in Atlanta by the Atlanta Business Chronicle (2023)
One of the Largest Certified Minority Business Enterprises (MBEs) in the United States (NMSDC, 2024)
AWS Advanced Tier Services Partner with 100+ certifications

INNOVA SOLUTIONS is an Equal Opportunity Employer and prohibits any kind of unlawful discrimination and harassment. Innova Solutions is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment on the basis of race, color, religion or belief, national origin, citizenship, social or ethnic origin, sex, age, physical or mental disability, veteran status, marital status, domestic partner status, sexual orientation, or any other status protected by the statutes, rules, and regulations in the locations where it operates.

If you are an individual with a disability and need a reasonable accommodation to assist with your job search or application for employment, please contact us at [e-mail] or (770) 493‑5588. Please indicate the specifics of the assistance needed.

INNOVA SOLUTIONS encourages all interested and qualified candidates to apply for employment opportunities.

INNOVA SOLUTIONS (HireGenics/Volt) does not discriminate against applicants based on citizenship status, immigration status, or national origin, in accordance with 8 U.S.C. § 1324b. The company will consider for employment qualified applicants with arrest and conviction records in a manner that complies with the San Francisco Fair Chance Ordinance, the Los Angeles Fair Chance Initiative for Hiring Ordinance, and other applicable laws.