PLADS Appeals Consultant
New
Fully remote work within the United StatesFull-TimeMiddle
Salary75,000 - 95,000 USD per year
Apply NowOpens the employer's application page
Job Details
- Experience
- 5+ years
- Required Skills
- Microsoft OfficeCompliance
Requirements
- Bachelor’s degree in healthcare, business, or a related field, or equivalent combination of education and experience.
- 5+ years of experience in disability, life, or group benefits claims, with direct involvement in appeals or complex claim reviews.
- Strong knowledge of ERISA regulations, including recent updates and compliance requirements.
- Experience with STD, LTD, Life, AD&D, waiver of premium, TPA, and voluntary benefit products.
- Familiarity with regulated insurance environments, including state and federal compliance frameworks.
- Strong analytical skills with the ability to interpret medical, vocational, and technical documentation.
- Excellent written and verbal communication skills, with strong attention to documentation accuracy.
- Proficiency in claim management systems and Microsoft Office tools.
- Ability to manage workload independently while maintaining quality and compliance standards.
- Strong interpersonal skills and ability to collaborate with clinical, legal, and operational teams.
Responsibilities
- Review and evaluate appeal requests across disability, life, and supplemental insurance products, ensuring compliance with policy provisions and regulatory requirements.
- Conduct comprehensive analysis of claim files, medical records, vocational data, and policy documentation to support fair and accurate appeal decisions.
- Ensure all determinations align with ERISA regulations, state laws, and internal compliance standards.
- Perform detailed research to interpret plan provisions and resolve complex case questions.
- Collaborate with medical directors, legal advisors, clinical experts, and other stakeholders to assess complex or high-risk cases.
- Document all findings, rationale, and decisions clearly within claim management systems for audit and reporting purposes.
- Communicate appeal outcomes in a clear, professional, and empathetic manner to claimants, employers, and partners.
- Manage assigned caseload efficiently to meet productivity, quality, and regulatory deadlines.
- Identify cases requiring escalation due to complexity, risk, or policy interpretation challenges.
- Support continuous improvement of claims processes and contribute to a positive customer experience.
View Full Description & ApplyYou'll be redirected to the employer's site
