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APPEALS SPECIALIST - 19-0011
PRINCIPAL OBJECTIVES:
To contribute to the overall success of OneAmerica objectives by providing timely and accurate support to our client companies and the Compliance department. To review and adjudicate claims on appeal to ensure accurate claim decisions according to policy provisions.
OneAmerica strives to ensure the independence and impartiality of all persons involved in making claim and appeal decisions. Accordingly, OneAmerica decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual are not made based upon the likelihood that the individual will support the denial of a benefit.
ESSENTIAL DUTIES/RESPONSIBILITIES:
• Reviews and adjudicates claims on appeal according to the policy provisions, ERISA, Fair Claim Settlement Practices Acts, and other statutory regulations.
• Conducts detailed reviews and resolves claims under appeal, DOI complaints and claims in litigation.
• Balances the demands of delivering superior service to the claimant while effectively managing the financial risk associated with each claim.
• Responds to all situations within ERISA or state law mandated timeframes.
• Provides ongoing feedback to respective team Managers, Supervisors, and Claim Examiners related to trend identification, learning opportunities and news related to litigated files and court rulings.
• Has superior claims knowledge within the claims department and among client carriers.
• Has an established network of peers within the industry with which to share ideas and new claim management techniques.
• Consults with medical, clinical and vocational professionals to obtain insight and clarity regarding claimants' medical conditions, recommended treatment plans and/or occupational requirements.
• Keeps current with industry practices and court rulings regarding proper claims management.
• Draws upon detailed knowledge base and highly developed skills to recommend solutions for complex situations and/or unique circumstances.
• Effectively manages an appeal caseload appropriate for the appeals specialist level and comprised of claims in varying stages of the appeal life cycle.
• Possesses a thorough understanding of, and maintains strict compliance with, client carriers' performance guarantees.
• Capable of effectively participating in depositions and/or providing trial testimony.
• Decisions are made independently, occasionally seeking consultative direction.
• Attends industry relevant continuing education seminars.
• Adheres to internal OneAmerica customer service guidelines and procedures.
• Demonstrates ability to identify basic legal issues associated with claims management in specific jurisdictions.
• Demonstrates ability to communicate effectively, negotiate conflict and influence others to effectuate the best possible decision for the claimant and the company.
• Demonstrates ability to effectively communicate benefit determinations – conveying a clear understanding of the relevant facts and detailing concisely the rationale for an adverse decision.
• Demonstrates ability to conduct internet research necessary for a thorough investigation of medical, factual and occupational aspects of claims.
• Assists in staff training with regard to appeal process and ERISA.
• Participates in special projects and performs other claims or company related duties on an ad hoc basis, as requested by management
• Four-year college degree or a combination of related work experience and education.
• Minimum of 2 to 5 years of claims experience in individual or group disability claims from a business or legal perspective.
• Some appeals experience preferred.
• Detailed knowledge of disability claim practices and claim management procedures for all claim levels.
• Detailed knowledge of all long-term and short-term disability contract provisions and their application.
• Working knowledge of Social Security law, Workers' Compensation statutes, statutory disability laws and pensions.
• Working knowledge of federal and state regulations as they apply to disability claims, including ERISA, state insurance laws, and Unfair Claims Practices regulations.
To contribute to the overall success of OneAmerica objectives by providing timely and accurate support to our client companies and the Compliance department. To review and adjudicate claims on appeal to ensure accurate claim decisions according to policy provisions.
OneAmerica strives to ensure the independence and impartiality of all persons involved in making claim and appeal decisions. Accordingly, OneAmerica decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual are not made based upon the likelihood that the individual will support the denial of a benefit.
ESSENTIAL DUTIES/RESPONSIBILITIES:
• Reviews and adjudicates claims on appeal according to the policy provisions, ERISA, Fair Claim Settlement Practices Acts, and other statutory regulations.
• Conducts detailed reviews and resolves claims under appeal, DOI complaints and claims in litigation.
• Balances the demands of delivering superior service to the claimant while effectively managing the financial risk associated with each claim.
• Responds to all situations within ERISA or state law mandated timeframes.
• Provides ongoing feedback to respective team Managers, Supervisors, and Claim Examiners related to trend identification, learning opportunities and news related to litigated files and court rulings.
• Has superior claims knowledge within the claims department and among client carriers.
• Has an established network of peers within the industry with which to share ideas and new claim management techniques.
• Consults with medical, clinical and vocational professionals to obtain insight and clarity regarding claimants' medical conditions, recommended treatment plans and/or occupational requirements.
• Keeps current with industry practices and court rulings regarding proper claims management.
• Draws upon detailed knowledge base and highly developed skills to recommend solutions for complex situations and/or unique circumstances.
• Effectively manages an appeal caseload appropriate for the appeals specialist level and comprised of claims in varying stages of the appeal life cycle.
• Possesses a thorough understanding of, and maintains strict compliance with, client carriers' performance guarantees.
• Capable of effectively participating in depositions and/or providing trial testimony.
• Decisions are made independently, occasionally seeking consultative direction.
• Attends industry relevant continuing education seminars.
• Adheres to internal OneAmerica customer service guidelines and procedures.
• Demonstrates ability to identify basic legal issues associated with claims management in specific jurisdictions.
• Demonstrates ability to communicate effectively, negotiate conflict and influence others to effectuate the best possible decision for the claimant and the company.
• Demonstrates ability to effectively communicate benefit determinations – conveying a clear understanding of the relevant facts and detailing concisely the rationale for an adverse decision.
• Demonstrates ability to conduct internet research necessary for a thorough investigation of medical, factual and occupational aspects of claims.
• Assists in staff training with regard to appeal process and ERISA.
• Participates in special projects and performs other claims or company related duties on an ad hoc basis, as requested by management
• Four-year college degree or a combination of related work experience and education.
• Minimum of 2 to 5 years of claims experience in individual or group disability claims from a business or legal perspective.
• Some appeals experience preferred.
• Detailed knowledge of disability claim practices and claim management procedures for all claim levels.
• Detailed knowledge of all long-term and short-term disability contract provisions and their application.
• Working knowledge of Social Security law, Workers' Compensation statutes, statutory disability laws and pensions.
• Working knowledge of federal and state regulations as they apply to disability claims, including ERISA, state insurance laws, and Unfair Claims Practices regulations.