Appeals Team Leader (Workplace Solutions) - Omaha, NE or Chattanooga, TN
Job no: 497145
Work type: Full Time Regular
Location: Nebraska, Tennessee
|Leads and supports Appeals team functions involving a high level of product complexity and financial risk within the Claims department. Oversees performance of associates and the execution of department, division and Company initiatives to improve business processes and foster profitable growth. Responsible for the monitoring and coaching of staff to ensure performance expectations are met. Conducts short range planning and assists with planning and implementing long range organizational projects and initiatives utilizing change management techniques and concepts. Demonstrates understanding and ability to practice lean concepts and techniques.
The Appeals Team Leader will oversee the handling of appeals for all lines of business, including Group short term disability, long term disability, life, AD&D, waiver of premium, critical illness, accident and all other products offered by Workplace Solutions. This position acts as a mentor, coach and trainer to claims staff and clients concerning appeals procedures and related risk management issues. Monitors and leads activities, identifies solutions, analyzes results and plans for implementing new procedures and techniques within the claim process workflow.
Essential Job Functions:
- Oversees the review of all information submitted, both pre and post adverse benefit determination for group short term disability, long term disability, life, AD&D, waiver of premium, critical illness and accident claim appeals.
- Ability to leverage contract language to support decisions. Overcomes objections that prevent payment of a claim through effective appeal negotiations.
- Guides client appeal activities, advising and serving as a technical expert. Recognizes opportunities for potential claim settlements. Actively seeks out opportunities for technological advancement, enhancements of procedures and efficiency of processes.
- 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 claims settlement philosophy.
- Researches and evaluates emerging federal common laws, Circuit & District level case laws and the impacts on group disability claim appeals. Ensures staff adherence to ERISA and other federal/state laws concerning group disability insurance. Remains current on Company and industry changes, federal and state regulations, as well as changes in internal processes and procedures.
- Presents cases to the appeals committee, responding to questions and obtaining additional information as requested.
- Mentors, coaches and trains claims staff and clients regarding the appeals process, procedures and related risk management issues. Coordinates input from appropriate staff to develop consolidated findings for the appeals team.
- Responds to reporting requests from both internal and external sources, extracting data and reporting in a logical manner. Coordinates the preparation of comprehension written reports of findings, including trending reports. Reports weekly, monthly, quarterly appeals' results to management.
- Analyzes and resolves complex claim appeals and legal files. Investigates appeal completions, coordinates responses with Appeals Specialists and creates action plans and develops recommendations to improve customer satisfaction. Handles escalated appeal calls.
- Plans, organizes, staffs, leads and controls activities pertaining to the Appeals department to include: planning projects, capital and human resource budgets; interviewing, selecting and training staff; monitoring and appraising performance of associates while holding them accountable for end results. Administers compensation and disciplinary action to direct reports and ensures the department complies with affirmative action guidelines.
- Monitors work progress and performance by via outlined service operational metrics to maintain the quality, quantity and time service of work produced by the department within established standards. Develops, implements and monitors quality assurance processes.
- Schedules and coordinates task and resource management during peak volumes and need-driven staff allocations. Collaborates with supporting departments to resolve any service delivery, system, and/or quality issues.
- Utilizes appropriate business judgment and sound customer service skills by providing effective support to internal stakeholders and/or external customers.
- Remains current on pertinent federal and state legislation affecting business processing and claims handling.
- Ensures all departmental activities support the division's effort to meet or exceed corporate policies, procedures, and/or directives while meeting or exceeding expense management objectives. Assesses and analyzes any areas of procedural non-compliance, modifies and/or enhances existing processes, and initiates corrective actions where appropriate. Leads and/or participates in cross-functional work groups that analyze, develop and implement processes, procedures and activities that enhance corporate profitability, efficiency and/or quality. Leads the development of short range business plans and budgets. Leads and/or participates in the planning and execution of organizational initiatives.
- Effectively represents the Appeals department as a subject matter expert within and outside of the division/operation. Interacts frequently with key external customers and internal stakeholders. Handles escalated issues. Exercises appropriate discretion in formulating and implementing business decisions within the department. Works with the Law Division on legal matters and may participate in depositions or trials.
- Reviews, analyzes and takes appropriate action to resolve claims issues, attorney inquiries.
- Establishes, implements and monitors training requirements and effectiveness. Develops and demonstrates strong leadership skills in the areas of talent, visionary and business leadership.
- This position requires extensive or prolonged typing/keyboarding.
- This position requires sitting over 66% of the time.
- This position requires Visual Acuity at 20 inches (or less) over 66% of the time.
- Thorough understanding of claim adjudication, benefit determination, investigation, file development, legal requirements, and contract interpretation.
- Experience interpreting state and federal laws and technical legal language including complex benefit plans to facilitate implementation of enhancements to systems, policy and procedures to ensure quality and compliance standards are maintained.
- Excellent verbal and written communication skills.
- Strong analytical and planning/organizational skills.
- Strong human relations skills with demonstrated ability to work with both internal and external customers to resolve issues and exert influence as appropriate
Ability to effectively plan, organize and manage multiple projects.
- Personal computer operation with skills in various software applications, including word processing, spreadsheets, electronic mail and presentation programs.
- Seasoned supervisory or leadership experience.
- Extensive product, distribution and Claims industry knowledge.
- Strong independent judgment, communication, presentation, planning and organizational skills.
- Effective analytical, problem-solving, and decision-making skills.
- Understanding of Corporate policies, philosophies and objectives.
- Ability to work in a fast-paced, dynamic environment.
- May require department-specific license, certifications and/or designations.
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 we will reply within 24 hours.
Mutual of Omaha and its affiliates are an Equal Opportunity /Affirmative Action Employer. Qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
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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 Standard Time
Applications close: Central Standard Time
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