Appeals Specialist (Group Claims)

In this role, you’ll leverage your expertise in claims adjudication, contract interpretation, and risk management to guide clients, overcome obstacles, and ensure fair, compliant decisions. You’ll collaborate with internal teams and the Law Division, communicate clearly and professionally with claimants and stakeholders, and manage multiple priorities with accuracy and attention to detail. This role also offers the opportunity to mentor and support staff while continuously improving processes and efficiency.

WHAT WE CAN OFFER YOU:

• Estimated Salary: (Levels have variable responsibilities and qualifications):
  • Appeals Specialist: $54,000 - $66,000 plus annual bonus opportunity.
  • Sr Appeals Specialist: $68,000 - $90,000 plus annual bonus opportunity.
• 401(k) plan with a 2% company contribution and 6% company match.
• Work-life balance with vacation, personal time and paid holidays. See our benefits and perks page for details.
• Applicants for this position must not now, nor at any point in the future, require sponsorship for employment.

WHAT YOU'LL DO:

• Reviews and evaluates all pre- and post-adverse benefit determination materials for Group STD, LTD, Life, AD&D, Waiver of Premium, CI and Accident appeals; overcomes objections through effective appeal arguments, escalates appropriately, and requests additional information as needed to clarify issues.
• Renders appeal decisions using medical, vocational and legal risk management resources; serves as a technical expert to guide client appeal activities and leverages contract language to support sound determinations.
• Prepares clear, professional written communications to claimants, representatives, policyholders, brokers and attorneys; documents actions thoroughly and maintains accurate records of appeal cause, disposition and trending.
• Ensures compliance with ERISA and applicable federal and state laws; researches and evaluates emerging case law and regulatory changes, presents cases in forums, and remains current on company, industry and legislative updates.
• Drives continuous improvement by identifying technological and process enhancements; mentors and trains staff and clients on appeals and risk management, contributes to internal policy development, and partners with operations to ensure alignment on key processes.

WHAT YOU’LL BRING:

• Prefer at least 6 years of direct Group Disability industry experience, thorough understanding of claims adjudication, benefit determination, investigation, file development, legal requirements, and contract interpretation, with the ability to conduct focused and extensive claims research.
• Demonstrated high-level risk management, analytical, mathematical, problem-solving, and decision-making skills, with strong persuasion, negotiation, and ability to interpret and communicate disability contract language.
• Excellent communication skills with the ability to remain professional and pleasant in interactions with coworkers, clients, claimants, vendors, and others; capable of conducting small group presentations and collaborating with the Law Division, including potential participation in depositions or trials.
• Ability to de-escalate situations on a regular basis and manage multiple priorities effectively.
• Superior attention to detail, flexibility, and the ability to work independently or as part of a team.
• You promote a culture of diversity and inclusion, value different ideas and opinions, and listen courageously, remaining curious in all that you do.
• Able to work remotely with access to a high-speed internet connection and located in the United States or Puerto Rico.

We value unique experience, skills, and passion for innovation. If your experience aligns with the listed requirements, please apply!

If you have questions about your application or the hiring process, email our Talent Acquisition area at . Please allow at least one week from time of applying if you are checking on the status.

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Salary: c21/c22 | Pay Scale: 100 C23 - Annual

Originally posted on Himalayas