STD Claims Appeals Specialist
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Job Description
Appeals Specialist conducting reviews, investigation, and analysis of Short-Term Disability appeals. Responsible for interpreting contract terms and applying ERISA requirements within a remote environment.
Responsibilities:
- 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 and resolve gaps in financial calculations and offsets when applicable, share technical knowledge and approach on financial calculations with team members
- Interpret calculations correctly involving complex contract provisions and work with applicable resources as needed to resolve issues
- 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
Requirements:
- 4 Year/Bachelor's degree or equivalent work experience (4 years of experience in lieu of Bachelor's)
- 3+ years of claims and/or appeals experience with LTD/STD claims
- Ability to communicate effectively (verbal/written)
- Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
Benefits:
- PTO/parental leave
- Competitive 401K and employee benefits
- Free financial counseling, health coaching and employee assistance program
- Tuition assistance program
- Working arrangements that work for you
- Effective productivity/technology tools and training
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