Ohio Licensed Appeals Specialist
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Job Summary
To support benefit plan administration, the full-time Ohio Licensed Appeals Specialist will manage member appeals and provider disputes remotely, ensuring compliance with regulations while delivering professional resolutions.
Key Responsibilities
- Manage appeals and disputes by reviewing, investigating, and resolving cases in accordance with plan documents and regulations
- Interpret complex plan documents and analyze claims to support accurate determinations
- Ensure compliance with regulatory requirements and maintain thorough documentation for audits and reviews
Required Qualifications
- Experience in medical claims processing and appeals, preferably in a Third-Party Administrator (TPA) environment
- Strong understanding of healthcare benefits administration and the ability to interpret complex plan documents
- Knowledge of CPT, ICD-10, and HCPCS coding and claim pricing methodologies
- Working knowledge of ERISA, ACA, and relevant state regulations
- Strong analytical skills with the ability to evaluate complex information and reach well-reasoned conclusions
Complete Job Description
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