Aflac · 9 hours ago
Appeals Consultant (PLADS)
United States
Full-time
Remote
Mid, Senior Level
$75K/yr - $95K/yr
5+ years expAflac is a Fortune 500 company and an industry leader in voluntary insurance products. The Appeals Consultant role involves reviewing and evaluating appeal requests, ensuring compliance with regulations, and communicating decisions to various stakeholders.
FinanceFinancial ServicesHealth CareInsurance
Responsibilities
Reviews and evaluates appeal requests across STD, LTD, Life, PW, AD&D, TPA, statutory and voluntary benefit products for fully insured and ASO customers
Conducts a complete review of claim files, medical documentation, policy information and related materials to support accurate and fair appeal decisions within required timeframes
Ensures decisions comply with ERISA, state regulations and internal policies and procedures
Performs research to clarify plan provisions, identify relevant information, and support case resolution
Consults with medical directors, clinical resources, legal team members, other internal stakeholders, and contracted external resources to gather input for more complex cases
Documents all findings, actions taken, and appeal determinations clearly and fully in the claim system to ensure proper audit and reporting practices
Communicates appeal decisions in a clear and professional manner to claimants, employers, and other stakeholders
Prioritizes and manages assigned workload to meet productivity, quality, and regulatory requirements
Identifies cases requiring escalation based on complexity, risk, or unique circumstances
Supports a positive customer experience by responding to questions and working collaboratively with internal partners
Performs other related duties as required
Qualification
Required
Proficient in ERISA regulations including 2018 regulatory changes/requirements
Demonstrated ability to analyze medical, vocational, and technical information to support claim/appeal decisions
Strong documentation, organization, and communication skills
Proficiency with claim management systems and Microsoft Office applications
Bachelor's Degree In healthcare, business, or a related field
5 or more years of job-related experience working with disability, life, or related group benefits, including direct involvement with appeal handling and/or complex claim review
Working knowledge of STD, LTD, Life, Premium Waiver, AD&D, TPA and voluntary product coverage for Fully Insured and ASO customers
Experience working within regulated environments (ERISA, DOI/DOL compliance)
Or an equivalent combination of education and experience
Benefits
Medical, dental, and vision coverage
Prescription drug coverage
Health care flexible spending
Dependent care flexible spending
Aflac supplemental policies (Accident, Cancer, Critical Illness and Hospital Indemnity offered at no costs to employee)
401(k) plans
Annual bonuses
Opportunity to purchase company stock
11 paid holidays
Up to 20 days PTO to be used for any reason
State-mandated sick leave (Washington employees accrue 1-hour sick leave for every 40 hours worked)
Other leaves of absence, if eligible
Company
Aflac
Aflac is a company that offers individuals and companies supplemental disability insurance.
10001+ employees
Funding
Current Stage
Public CompanyTotal Funding
unknown1974-06-14IPO
Leadership Team
JR Shamley
SVP National Accounts Business Development & Growth Solutions
Matthew D. Owenby
SVP, Chief Human Resources Officer and Corporate Services Executive
Recent News
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