Specialist, Appeals Claims (Short-Term Disability)

Specialist, Appeals Claims (Short-Term Disability)

As an Appeals Specialist you will be responsible for being a product subject matter expert to provide full, fair appeal reviews for multiple product lines. You will perform and deliver on appeals claims assignments / projects while simultaneously leveraging and applying knowledge. You will analyze and manage a caseload of appeals claims. You will review, investigate, and make claim determinations regarding coverage, compensability, and appropriateness of claims. You will provide technical information and detailed guidance to Claims management & teams regarding products, claims processes, regulations, and applicable systems for their assigned claims area. If this sounds like a role for you, please read on!

Analyze & process claims by investigating & obtaining a wide range of complex information. Apply claim policies & procedures and engages intervention of internal / external resources to ensure fair, ethical, & timely management of assigned claims.

Analyze and interpret complex coverage contracts to determine if eligibility is met.

Identify, interpret, and resolve gaps in financial calculations and offsets when applicable, share technical knowledge and approach on financial calculations with team members that involve complex contract provisions.

Research questions and escalations from Claims team; liaises with various stakeholders from across the business (Underwriting, Actuarial, Compliance, Account Management, etc.) to obtain needed information to clarify and address issues.

Provide customers with in-depth explanations of policy details, claim process, and claim determination; ensure parties understand the information and outcome.

Utilize internal reporting to identify trends and review / audit performance against team metrics; propose and develop practices & processes to improve performance and the customer experience.

Effectively utilize and implement policies & procedures regarding medical terminology, duration, functionality documentation, and overall claims workflow. Provide detailed guidance & coaching to junior team members.

Must-have : 4 Year / Bachelor's degree or equivalent work experience (4 years of experience in lieu of Bachelor's). 1 - 3+ Years of Short-Term and / or Long-Term Disability. (Required). Ability to communicate effectively (verbal / written). Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).

Nice-to-have : Experience working with multiple products. Presentation training or skills. Demonstrates excellent organizational skills with the ability to prioritize workload and multi-task while maintaining strict attention to detail. SystemOne experience.