Appeals Specialist

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Reviews outcomes of adverse determinations for Short Term Disability and Long-Term Disability claims.

• Ensures adherence to regulatory standards while making fair, comprehensive, and prompt appeal decisions.

• Plans, implements, and executes the investigation process for disputed STD and LTD claims.

• Effectively tracks and manages an assigned caseload of claim appeals.

• Evaluates medical, financial, and non-medical data as needed, consulting with internal and external professionals regarding disputed issues to facilitate claim resolution.

• Provides clear communication to insured individuals, plan holders, attorneys, and other relevant parties concerning disputed matters.

• Interprets policy provisions, federal and state regulations, departmental procedures, and compliance directives.

• Mentors Specialists and offers guidance on interpreting and administering contract language.

• Provides feedback to assess training needs for organizational development offerings aimed at enhancing appeal administration skills.

⛳️ Requirements

• A minimum of three years of experience in STD/LTD product and claims management.

• Familiarity with state and federal compliance issues affecting claims administration and appeals.

• Experience with ERISA compliance in claim review processes.

• Work background involving medical knowledge (e.g., medical terminology, medical conditions).

• Demonstrates sound judgment, professionalism, and the ability to manage confidential information effectively.

• High School diploma or equivalent education is required (Bachelor’s degree is preferred).

• Intermediate proficiency in Microsoft Office applications, including Outlook and Word.

• Exhibits strong interpersonal (both oral and written) communication skills and a positive demeanor.

• Organized, capable of multitasking, and adept at identifying priorities.

🏝️ Benefits

• Health, dental, and vision coverage starting from Day One.

• Wellbeing programs.

• Retirement plans with contribution matching.

• Generous time off policy.

• Parental leave.

• Opportunities for continuing education.

• Career growth potential.