Remote Appeals & Disputes Specialist – Health Benefits

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

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.