8959 - Sr. Appeals Specialist | Apply For Insurance & Financial Services Jobs

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About the role The Appeals Specialist uses in-depth knowledge of Short-Term Disability, Long Term Disability, Life, and Waiver of Premium claims processing to conduct thorough appeals reviews of terminated or denied claims and render an appeal decision. The Appeals Specialist follows department established guidelines and workflows and also adheres to ERISA and other regulatory guidelines and timeframes to prevent risk of penalties/fines. The Appeals Specialist will also work with the Compliance department to handle and respond to complaints filed on claims. What you will do Review appealed claims in accordance with appropriate Short-Term Disability, Long Term Disability, or Life plan/policy provisions. Develop action plans for handling appealed claims. - Implement action plans for appealed claims, which includes: contacting claimant/claimant representatives (such as attorneys) to discuss the case; contacting providers to obtain medical information; contacting employers to obtain information; and requesting medical/vocational review. Utilize tolling and extensions when appropriate during the course of appeal reviews. Determine appropriate type of specialty review required (vocational or medical specialty and type of review needed - peer review, IME, Occupational and/or Employability Assessment) and develop specific questions to be addressed to render an accurate appeal decision. Resolve appeals timely (within mandated timeframes) and communicate appeal outcomes to appropriate parties. - Identify trends noted through appeal reviews and communicate trends to Management team for addition developmental opportunities for staff. Work with Compliance in handling and responding to complaints filed on claims, including those filed through state insurance departments, executive and presidential complaints, etc. Create/maintain recordkeeping of new and ongoing complaint activity in required systems through to the resolution and closure of the complaint. Maintain communications with appropriate parties related to all complaint activity. Research and compile data and provide a drafted response to the complaint with supporting documentation for review to Compliance Officer, and Law Department when appropriate. Send final response to complaint to appropriate party within the required timeframes. Perform claim audits for Short Term Disability, Long Term Disability, Life and Waiver of Premium claims. Evaluate and measure claim activities against quality assurance standards and verify compliance with department guidelines, processes and procedures. - Analyze audit data to identify trends and opportunities. Why Work at Symetra Here's what some of our employees have to say about why they work at Symetra: \"What I was searching for was a company that genuinely valued my voice--and I found that at Symetra. I truly enjoy working one-on-one with our customers, especially when they're going through life's toughest moments. Being able to offer support and hear their relief and gratitude when we help--it's deeply meaningful. That's what makes me proud to be part of the Symetra team.\" \\- Lilly H., Claims Team Lead \"I chose Symetra because I heard it was a pro-employee company--and it's absolutely true. The work environment is supportive, the people are great, and the benefits are generous. Symetra truly cares about its employees. The relaxed atmosphere and opportunities to learn and grow--both within your role and beyond--make it a great place to build your career.\" \\- Alicia L., Claims Examiner What we offer you Benefits and Perks We don't take a \"one-size-fits-all\" approach when it comes to our employees. Our programs are designed to make your life better both at work and at home. Flexible full-time or hybrid telecommuting arrangements Plan for your future with our 401(k) plan and take advantage of immediate vesting and company matching up to 6% Paid time away including vacation and sick time, flex days and ten paid holidays Give back to your community and double your impact through our company matching Want more details? Check out our Symetra Benefits Overview Compensation Salary Range: $64,200 -$106,900 plus eligibility for annual bonus program Who You Are Knowledge of ERISA (Employer Retirement Income Security Act), HIPAA (Health Insurance Portability and Accountability Act), FIT (Federal Income Tax) and insurance laws of the United States. - Strong knowledge of Short-Term Disability, Long Term Disability, Life and Waiver of Premium claims processing. High degree of knowledge in medical terminology, claims processing, and benefit calculations. - Ability to assess appropriate type of specialty review required (vocational or medical specialty and type of review needed - peer review, IME, Occupational and/or Employability Assessment, etc) - Experience with litigated claim matters. Familiarity with federal and state regulations. Proficiency in Microsoft Office and related software. High School Diploma required. We empower inclusion At Symetra, we aspire to be the most inclusive insurance company in the country. We're building a place where every employee feels valued, respected, and has opportunities to contribute. Inclusion is about recognizing our assumptions, considering multiple perspective, and removing barriers. We accept and celebrate diverse experiences, identities, and perspectives, because lifting each other up fuels thought and builds a stronger, more innovative company. We invite you to learn more about our efforts here. Creating a world where more people have access to financial freedom Symetra is a national financial services company dedicated to helping people achieve their financial goals and feel confident about the future. In our daily work, we're guided by the principles of Value, Transparency and Sustainability. This means we provide products and services people need at a competitive price, we communicate clearly and openly so people understand what they're buying, and we design products--and operate our company--to stand the test of time. We're committed to showing up for our communities, lifting up our employees, and standing up for diversity, equity and inclusion (DEI). Join our team and help us create a world where more people have access to financial freedom. For more information about our careers visit: https://symetra.eightfold.ai/careers Work Authorization Employer work visa sponsorship and support are not provided for this role. Applicants must be currently authorized to work in the United States at hire and must maintain authorization to work in the United States throughout their employment with our company. Please review Symetra's Remote Network Minimum Requirements: As a remote-first organization committed to providing a positive experience for both employees and customers, Symetra has the following standards for employees' internet connection: Minimum Internet Speed: 100 Mbps download and 20 Mbps upload, in alignment with the FCC's definition of \"broadband.\" Internet Type: Fiber, Cable (e.g., Comcast, Spectrum), or DSL. Not Permissible: Satellite (e.g., Starlink), cellular broadband (hotspot or otherwise), any other wireless technology, or wired dial-up. 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