Appeals Specialist

Job Summary

Leveraging expertise in claims adjudication and risk management, the full-time remote Appeals Specialist will guide clients through the appeals process, ensuring compliance and fair decisions while collaborating with internal teams and mentoring staff.

Key responsibilities

• Review and evaluate pre- and post-adverse benefit determination materials for various group claims and develop effective appeal arguments
• Render appeal decisions utilizing medical, vocational, and legal resources, serving as a technical expert in client appeal activities
• Prepare clear written communications for stakeholders, ensuring compliance with ERISA and relevant laws while driving continuous improvement in processes

Required qualifications

• At least 6 years of direct Group Disability industry experience with a thorough understanding of claims adjudication and contract interpretation
• Demonstrated high-level risk management and analytical skills, with the ability to effectively communicate and negotiate
• Proven ability to manage multiple priorities and de-escalate situations while maintaining professionalism in interactions
• Experience in conducting presentations and collaborating with legal teams, including potential participation in depositions or trials
• Access to high-speed internet and located in the United States or Puerto Rico for remote work