Appeals & Disputes Specialist - REMOTE

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

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…