Appeals & Disputes Specialist - REMOTE

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.