Remote Appeals & Disputes Specialist

S&S Healthcare; Cincinnati (OH); Remoto; USD 50.000 - 60.000; Tempo pieno

Descrizione del lavoro

Reflect Health, an independent administrator, seeks an Appeals & Disputes Specialist for remote work. You will review, investigate, and resolve member appeals and provider disputes, ensuring accurate, timely determinations in line with plan documents and regulations.

The role requires experience with medical claims processing, CPT/ICD-10/HCPCS coding, ERISA, ACA, CMS rules, and strong analytical and communication skills.

Competenze

• Experience in medical claims processing or adjudication.
• Ability to interpret complex plan documents and benefit language.
• Knowledge of ERISA, ACA, CMS requirements, and state regulations.
• Strong analytical and problem-solving abilities.
• Excellent written and verbal communication skills.

Mansioni

• Review, investigate, and resolve member appeals and provider disputes.
• Ensure timely, accurate determinations per plan documents and laws.
• Maintain complete case records and audit-ready files.
• Collaborate with Claims, Compliance, Legal, and Provider Relations.
• Identify process improvements to improve decision quality and efficiency.
• Prepare clear determination letters and communicate outcomes.

Conoscenze

Appeals experience

Disputes resolution

Plan interpretation

Regulatory knowledge

Analytical thinking

Communication skills

Documentation & records

Process improvement

Strumenti

Microsoft Office

Claims management systems

Virtual collaboration platforms

Descrizione del lavoro

Reflect Health, an independent administrator, seeks an Appeals & Disputes Specialist for remote work. You will review, investigate, and resolve member appeals and provider disputes, ensuring accurate, timely determinations in line with plan documents and regulations.

The role requires experience with medical claims processing, CPT/ICD-10/HCPCS coding, ERISA, ACA, CMS rules, and strong analytical and communication skills.