Appeals & Disputes Specialist

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Review, investigate, and resolve member appeals and provider disputes in an accurate and timely manner.

• Interpret Summary Plan Descriptions, Summaries of Benefits and Coverage, employer-specific provisions, Stop-Loss provisions, medical records, CPT/ICD-10/HCPCS coding, billing information, and claim pricing methodologies.

• Apply ERISA, ACA, CMS, state regulatory requirements, and internal service-level agreements.

• Maintain comprehensive case records, determination letters, supporting documentation, and files that are ready for audit.

• Collaborate with Claims, Clinical, Compliance, Legal, Provider Relations, Customer Service, and Account Management teams.

• Resolve complex or escalated cases and refer high-risk, litigation-sensitive, or regulatory issues to the appropriate leadership.

• Assist with internal audits, regulatory reviews, complaint investigations, and documentation requests.

• Analyze recurring trends in appeals and disputes, investigate root causes, and recommend enhancements to processes.

• Contribute to the development of appeals policies, procedures, workflows, and best practices.

• Communicate the outcomes of appeals and the supporting rationale professionally to members, providers, attorneys, regulatory agencies, and internal stakeholders.

⛳️ Requirements

• Experience in medical claims processing, analysis, or adjudication, ideally within a Third-Party Administrator (TPA) setting.

• Proven experience in investigating medical appeals, provider disputes, and complex claims issues.

• Strong comprehension of healthcare benefits administration and self-funded, level-funded, and fully insured health plans.

• Ability to interpret intricate plan documents, benefit language, employer-specific provisions, and associated documentation.

• Knowledge of CPT, ICD-10, and HCPCS coding, claim pricing methodologies, reimbursement principles, and factors influencing claim adjudication and appeal outcomes.

• Working familiarity with ERISA, the Affordable Care Act (ACA), applicable CMS requirements, state regulations, and compliance considerations pertinent to healthcare benefits and appeals resolution.

• Excellent investigative, critical-thinking, and problem-solving abilities.

• Outstanding written and verbal communication skills.

• Strong organizational and time-management capabilities, with the proficiency to manage multiple cases and competing deadlines while ensuring accuracy and quality.

• Ability to work both independently and collaboratively with internal teams and external stakeholders.

• Proficiency in Microsoft Office, virtual collaboration platforms, and relevant claims or case management systems.

• All final candidates will undergo a comprehensive background check and drug testing.

🏝️ Benefits

• Comprehensive health insurance coverage.

• Retirement plan options with company matching.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and continuing education.