Appeals & Disputes Specialist - REMOTE

Reflect Health; Cincinnati (OH); Remote; USD 50,000 - 60,000; Full time

Job summary

Reflect Health is seeking an Appeals & Disputes Specialist to review, investigate, and resolve member appeals and provider disputes with a focus on compliant and timely determinations. This remote role supports plan interpretation, coding review, and collaboration with multiple internal teams to ensure accurate outcomes.

The position requires knowledge of ERISA, ACA, CMS requirements, and strong analytical and communication skills.

Qualifications

• Experience in medical claims processing, analysis, or adjudication.
• Experience investigating medical appeals and provider disputes.
• Understanding of healthcare benefits administration and self-funded, level-funded, and fully insured plans.
• Knowledge of CPT, ICD-10, and HCPCS coding, and claim pricing methodologies.
• Knowledge of ERISA, ACA, CMS requirements and state regulations.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong organizational and time-management skills.
• Ability to work independently and with cross-functional teams.

Responsibilities

• Review, investigate, and resolve member appeals and provider disputes accurately and timely.
• Analyze SPDs, SBCs, provider documentation, and coding to support accurate determinations.
• Ensure compliance with ERISA, ACA, CMS and state regulations; maintain audit-ready documentation.
• Collaborate with Claims, Clinical, Compliance, Legal, and Provider Relations to resolve complex cases.
• Assist with audits and regulatory reviews by providing case records and analysis.
• Identify process improvements to improve decision quality and efficiency.

Skills

Analytical thinking

Communication

Organization

Collaboration

Problem solving

Attention to detail

Tools

Microsoft Office

Claims systems

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Appeals & Disputes Specialist - REMOTE

Executive Team ** Office and Clerical Ohio Corp. Office, Cincinnati, OH, US

3 days ago Requisition ID: 1367

Salary Range: $50,000.00 To $60,000.00 Annually

Reflect Health is the evolution of S&S Health, a trusted independent third-party administrator founded in 1994 to meet the growing need for access, simplified connectivity, and benefits administration. Headquartered in Mason, OH, we have built a reputation based on innovation, service excellence, and a deep understanding of how to drive better outcomes at lower cost. Over the years, we grew into a national presence serving employers, TPAs, health systems, and benefit consultants across all 50 states. We developed proprietary claims technology, expanded our offerings to include level-funded and fully funded programs, and delivered tangible savings and enhanced experiences for millions of members.

The Appeals & Disputes Specialist is responsible for reviewing, investigating, and resolving member appeals and provider disputes for benefit plans, ensuring accurate, timely, and compliant determinations in accordance with plan documents, employer-specific requirements, and applicable federal and state regulations. This role works cross-functionally to support consistent decision-making, identify opportunities for process improvement, and help protect the integrity of benefit administration while delivering a professional and responsive experience for members and providers.

Key Responsibilities

• Manage Appeals & Disputes: Review, investigate, and resolve member appeals and provider disputes accurately and timely in accordance with plan documents, benefit policies, employer-specific requirements, and applicable regulations.
• Interpret Plans & Analyze Claims: Review Summary Plan Descriptions (SPDs), Summaries of Benefits and Coverage (SBCs), employer-specific provisions, Stop-Loss provisions, medical records, CPT/ICD-10/HCPCS coding, billing information, and claim pricing methodologies to support accurate, well-supported determinations.
• Ensure Compliance & Maintain Documentation: Apply applicable ERISA, ACA, CMS, state regulatory requirements, and internal service-level agreements. Maintain complete case records, determination letters, supporting documentation, and audit-ready files in accordance with internal procedures and regulatory standards.
• Resolve Complex Cases & Escalate Risks: Collaborate with Claims, Clinical, Compliance, Legal, Provider Relations, Customer Service, and Account Management to resolve complex or escalated cases, address discrepancies, and refer high-risk, litigation-sensitive, or regulatory matters to appropriate leadership.
• Support Audits & Regulatory Reviews: Assist with internal audits, regulatory reviews, complaint investigations, and documentation requests by providing accurate case records and supporting analysis.
• Identify Process Improvements: Analyze recurring appeal and dispute trends, investigate root causes, and recommend improvements to decision quality, consistency, operational efficiency, and compliance.
• Maintain Policies & Provide Expertise: Contribute to appeals policies, procedures, workflows, and best practices while serving as a resource for complex claims analysis, benefit interpretation, and dispute resolution.
• Communicate Decisions & Findings: Communicate appeal outcomes, supporting rationale, and related matters professionally to members, providers, attorneys, regulatory agencies, and internal stakeholders while maintaining confidentiality and appropriate documentation.

Qualifications

• Claims & Appeals Experience: Experience in medical claims processing, analysis, or adjudication, preferably in a Third-Party Administrator (TPA) environment, with experience investigating medical appeals, provider disputes, and complex claims issues.
• Benefits & Plan Interpretation: Strong understanding of healthcare benefits administration and self-funded, level-funded, and fully insured health plans. Ability to interpret complex plan documents, benefit language, employer-specific provisions, and related documentation. Experience with self-funded and level-funded plans preferred.
• Coding & Claims Analysis: Knowledge of CPT, ICD-10, and HCPCS coding, claim pricing methodologies, reimbursement principles, and factors affecting claim adjudication and appeal outcomes.
• Regulatory Knowledge: Working knowledge of ERISA, the Affordable Care Act (ACA), applicable CMS requirements, state regulations, and compliance considerations relevant to healthcare benefits and appeals resolution.
• Analytical & Problem-Solving Skills: Strong investigative, critical-thinking, and problem-solving skills, including the ability to evaluate complex information, identify discrepancies, assess supporting evidence, and reach well-reasoned conclusions.
• Communication Skills: Excellent written and verbal communication skills, including the ability to prepare clear determination letters, maintain accurate case records, and communicate complex or sensitive matters professionally.
• Organization & Collaboration: Strong organizational and time-management skills, with the ability to manage multiple cases and competing deadlines while maintaining accuracy and quality. Ability to work independently and collaboratively with internal teams and external stakeholders.
• Technology & Process Improvement: Proficiency in Microsoft Office, virtual collaboration platforms, and relevant claims or case management systems. Ability to identify process improvement opportunities; experience improving appeals or dispute resolution workflows preferred.

Reflect Health is committed to providing a safe and secure workplace for all employees. Please note that all final candidates will undergo a comprehensive background check and drug testing as part of our hiring process.