Appeals & Disputes Specialist

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🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $50k - $60k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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S&S Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1994

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

S&S Health is a modern health administration provider dedicated to offering affordable healthcare solutions for employers and their employees. By focusing on cost management, S&S Health helps businesses reduce healthcare expenses while maintaining high-quality care. With end-to-end support, they provide tools and resources to ensure that employees have access to the right medical care at competitive prices, ultimately aiming to improve both health outcomes and financial wellbeing.

📋 Description

• Review, investigate, and resolve member appeals and provider disputes accurately and timely • 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 complete case records, determination letters, supporting documentation, and audit-ready files • Collaborate with Claims, Clinical, Compliance, Legal, Provider Relations, Customer Service, and Account Management • Resolve complex or escalated cases and refer high-risk, litigation-sensitive, or regulatory matters to appropriate leadership • Assist with internal audits, regulatory reviews, complaint investigations, and documentation requests • Analyze recurring appeal and dispute trends, investigate root causes, and recommend process improvements • Contribute to appeals policies, procedures, workflows, and best practices • Communicate appeal outcomes and supporting rationale professionally to members, providers, attorneys, regulatory agencies, and internal stakeholders

🎯 Requirements

• Experience in medical claims processing, analysis, or adjudication, preferably in a Third-Party Administrator (TPA) environment • Experience investigating medical appeals, provider disputes, and complex claims issues • 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 • Knowledge of CPT, ICD-10, and HCPCS coding, claim pricing methodologies, reimbursement principles, and factors affecting claim adjudication and appeal outcomes • Working knowledge of ERISA, the Affordable Care Act (ACA), applicable CMS requirements, state regulations, and compliance considerations relevant to healthcare benefits and appeals resolution • Strong investigative, critical-thinking, and problem-solving skills • Excellent written and verbal communication skills • 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 • 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

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