Appeals Consultant (PLADS)
About The Position
We are the duck. We develop and empower our people, cultivate relationships, give back to our community, and celebrate every success along the way. We do it all…The Aflac Way. Aflac, a Fortune 500 company, is an industry leader in voluntary insurance products that pay cash directly to policyholders and one of America's best-known brands. Aflac has been recognized as Fortune’s 50 Best Workplaces for Diversity and as one of World’s Most Ethical Companies by Ethisphere.com. Our business is about being there for people in need. So, ask yourself, are you the duck? If so, there’s a home, and a flourishing career for you at Aflac. Worker Designation – This role is a remote role. This means you will be expected to work from your home, within the continental US. If the role is remote, there may be occasions that you are requested to come to the office based on business need. Any requests to come to the office would be communicated with you in advance. What does it take to be successful at Aflac? Acting with Integrity Communicating Effectively Pursuing Self-Development Serving Customers Supporting Change Supporting Organizational Goals Working with Diverse Populations
Requirements
- 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
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.
Benefits
- medical
- dental
- 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
- an opportunity to purchase company stock
- 11 paid holidays
- up to 20 days PTO
- state-mandated sick leave
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
