Appeals Specialist

Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. Its an opportunity to do something meaningful, each and every day. Its having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.

A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if youre someone who cares, theres a place for you here. Join us and contribute to Sedgwick being a great place to work.

Great Place to Work® Most Loved Workplace® Forbes Best-in-State Employer

PRIMARY PURPOSE : To facilitate the denied disability (short-term, long-term and accident) claim appeal review process by observing all aspects of the ERISA law; and to serve as the liaison between the review unit and the claims operation.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Gathers and reviews denied disability claim appeal documentation including, but not limited to, appeal request letters, medical documentation, medical consultant reviews, surveillance reports, independent medical evaluation reports and functional capacity evaluation reports.
• Reviews medical documentation and provides clinical and claim expertise on appealed claims.
• Prepares written response to appeal request letters within the legislative timeframes.
• Prepares appropriate communication to client and claim operation summarizing the appeal review determination.
• Monitors and tracks the number of appealed claims.
• Provides training to the claim operation regarding the claim appeal process.
• Ensures integrity of the claim appeal process and ensures compliance with ERISA legislation.
• Adheres to the highest quality and ethical standards when reviewing appealed claims and making determinations.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organizations quality program(s).

QUALIFICATIONS

Education & Licensing

Bachelors degree from an accredited college or university preferred. Licenses as required.

Experience

Four (4) years of related technical claims management or equivalent combination of education and experience experience required. Related field specialty experience is preferred.

Skills & Knowledge

• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

NOTE : Credit security clearance, confirmed via a background credit check, is required for this position.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.