Appeals Specialist

Job Summary

A company is looking for an Appeals Specialist (Group Claims) to manage claims adjudication and support clients in a remote setting.

Key Responsibilities

• Review and evaluate benefit determination materials for various appeals, providing effective arguments and requesting additional information as needed
• Render appeal decisions using medical, vocational, and legal resources, serving as a technical expert in client appeal activities
• Prepare professional written communications and maintain accurate records of appeal causes and dispositions while ensuring compliance with relevant laws

Required Qualifications, Training, and Education

• Minimum of 10 years of Group Disability experience with a thorough understanding of claims adjudication and legal requirements
• Demonstrated high-level risk management and analytical skills, with strong persuasion and negotiation abilities
• Ability to conduct small group presentations and collaborate with legal teams
• Capability to manage multiple priorities effectively and de-escalate situations regularly
• Access to high-speed internet and ability to work remotely from the United States or Puerto Rico