Sr Appeals Specialist
Core
Review and decide on appealed claims for Short Term Disability, Long Term Disability, Life, and Waiver of Premium plans, ensuring compliance with ERISA and regulatory guidelines.
Role type
Senior Claims Appeals Specialist
Builds
Final appeal decisions and compliant responses to regulatory complaints
Domain
Insurance (Disability, Life) and Regulatory Compliance
Deliverable
client delivery
Required skills
Claims adjudication, ERISA compliance, regulatory research, stakeholder communication, trend analysis, medical/vocational review coordination
Preferred skills
College degree, experience with state insurance department complaints
Technologies
Claims management systems, compliance tracking tools
Responsibilities
Review appealed claims against policy provisions; contact claimants, providers, and employers to gather information; determine and execute specialty reviews (medical/vocational); resolve appeals within mandated timeframes; handle and respond to regulatory complaints; identify and report trends to management