Appeals Specialist / Sr. Appeals Specialist (Claims Appeals Support Services) - Omaha, NE or Chattanooga, TN
Job no: 496368
Work type: Full Time Regular
Location: Nebraska, Tennessee
Categories: Claims/Claims Processing
|Under general supervision, this position will apply knowledge and experience while evaluating that appeal criteria is met. Responsible for applying analytical thought to review end to end appeals assessments, and compose effective arguments utilizing contractual language to support reconsideration. Responsible for composing effective written communication to summarize the appeals request, status and decision determination.
Essential Job Functions:
- Reviews all information submitted, both pre and post adverse benefit determination, for short & long term disability and life claim appeals. Overcomes objections that prevent payment of a claim through effective appeal arguments and has judgement to escalate as appropriate. Requests submission of additional information to clarify issues as necessary. Researches and evaluates both disputed and known liability claims for settlement opportunities.
- Renders decisions on claim appeals utilizing risk management resources (i.e., medical, vocational, legal resources). Guides client appeal activities, advising and serving as a technical expert. Ability to leverage contract language to support decisions. Recognizes opportunities for potential claim settlements.
- Composes effective, efficient and professional written communications to claimants, their representatives, group policyholders, brokers and attorneys. Documents all actions in a clear concise manner. Maintains accurate records of cause / origin, disposition, and trending of appeals. Identifies, evaluates and provides constructive feedback on risk management trends and issues as they pertain to settlements. Successfully balances results with high degree of fairness and integrity in support of the Mutual of Omaha claim settlement philosophy.
- Researches and evaluates emerging Federal Common laws, Circuit & District level case laws and the impacts on group disability appeals. Presents cases to the appeals committee, responding to questions and obtaining additional information as requested. Responds to reporting requests from both internal and external sources, extracting data and reporting it in a logical manner.
- Actively seeks out opportunities for technological advancements and enhancements of procedures and efficiency of process. Mentors, coaches and trains claims staff and clients regarding the appeals process, procedures and related risk management issues.This position requires extensive or prolonged typing/keyboarding.
- This position requires up to 33% travel, which may include flying and/or driving and some overnight stays.
- This position requires sitting over 66% of the time.
- This position requires Visual Acuity at 20 inches (or less) over 66% of the time.
- Ability to de-escalate situations on a regular basis.
- Ability to conduct focused and extensive research on claims situations.
- Superior attention to detail.
- Ability to work independently and in a team environment.
- Excellent communication skills, with the ability to be pleasant and professional during interactions with co-workers, clients, claimants, vendors and others.
- Ability to conduct small group presentations.
- Strong mathematical, analytical, problem solving and decision-making skills.
- Strong persuasion and negotiation skills. Ability to interpret and communicate disability contract language.
- Proven record of successful claims resolution through settlement activity. Demonstrated high-level risk management skills.
- Flexibility to manage multiple tasks simultaneously. Ability to initiate and prioritize regular work duties and projects.
- Strong computer skills, proficient in PC environment and MS Word, Excel and Outlook.
- Ability to act as mentor, coach, trainer to claims staff and clients regarding the appeals process, settlement procedures and related risk management issues.
- Ability to maintain regular and predictable attendance in adherence to department and company attendance expectations.
- Minimum 5-7 years work experience managing group short term and or long term disability claims with consistently meeting all job expectations.
- Participates in the development of internal policies and procedures.
- Participates in industry meetings.
For inquiries about the position or application process, contact our HR Helpline at 1-800-365-1405.
If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact a Human Resources Representative at 1-800-780-0304. We are available Monday through Friday 7 am to 4:30 pm CST.
Mutual of Omaha and its affiliates are an Equal Opportunity /Affirmative Action Employer, Minorities/Female/Disabled/Veteran
To All Recruitment Agencies: We do not accept unsolicited agency resumes and we are not responsible for any fees related to unsolicited resumes.
Advertised: Central Daylight Time
Applications close: Central Daylight Time
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