Appeals Specialist R-30699

This is a Job Description for Appeals Specialist

Summary: Are you interested in joining a collaborative Appeals team? As an Appeals Specialist, youll review adverse determinations for Short-Term Disability (STD) and Long-Term Disability (LTD) claims, ensuring compliance with legal and ethical standards. Youll make appeal decisions based on claim file information and additional submissions, adhering to ERISA/Department of Labor guidelines and ensuring accuracy for non-ERISA plans. This role requires staying up-to-updated on regulatory requirements and making fair, thorough, and timely determinations with a focus on quality and accuracy.

Duties & Responsibilities: Manage the investigation of disputed Short-Term Disability (STD) and Long-Term Disability (LTD) claims, ensuring each case is effectively tracked and managed through the appeals process. Assess medical, financial, and non-medical information with the support of internal and external experts to resolve disputed claims. Provide clear, comprehensive communication with insured individuals, plan holders, attorneys, and other parties via phone, email, and mail on claim-related issues. Interpret policy provisions, and ensure compliance with state and federal regulations, department procedures, and directives. Serve as a mentor to Specialists by offering guidance on interpreting and administering contract language. Offer constructive feedback to help identify training needs and participate in ongoing professional development to enhance appeal administration skills.

Requirements

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: High school diploma or equivalent level of education required; bachelors degree preferred. Proficiency with Microsoft Office, especially Outlook and Word. At least three years of experience with STD/LTD claims and product management. In-depth understanding of state and federal compliance issues related to claims and appeals, including ERISA. Familiarity with medical terminology and conditions. Strong judgment, professionalism, and ability to handle confidential information. Excellent interpersonal skills, both written and verbal, with a positive, proactive attitude. Highly organized, with the ability to multi-task and prioritize effectively

Equal

Opportunity/Affirmative Action Employer.