Lead Claims Adjuster - Appeals

Fetch

3d•$58,000 - $65,000•Remote

About The Position

The Lead Claims Adjuster - Appeals is a specialized, high-impact role within the Specialty Claims team responsible for the final internal adjudication of disputed claims. This role requires expert-level policy knowledge, meticulous attention to detail, and the ability to provide empathetic yet firm communication to pet parents regarding complex claim determinations. This position will manage the full lifecycle of the appeals process - from initial intake and medical record review to final determination and underwriting referrals balancing regulatory timelines with claims integrity. Beyond standard appeals, this Lead serves as the primary point of contact for the insurance department regarding sensitive escalations, including Department of Insurance (DOI) and Better Business Bureau (BBB) complaints, as well as legal inquiries related to claim determinations. The Lead will also be cross-trained to support Special Investigations (SIU) and auditing of high-value claims.

Requirements

Demonstrated ability to apply strong initiative and independent judgment to manage complex tasks while maintaining a clear view of the overall business objectives.
Superior written and verbal communication skills with the ability to explain complex policy language and investigative findings clearly and concisely to policyholders and legal entities.
Proven capacity for critical thinking and analytical problem-solving in a high volume environment.
Excellent team player committed to collaboration and applying innovative ideas to claims integrity.
Highly organized and able to anticipate needs, innovate, and thrive in a high-volume, fast-paced environment.
Work independently in a remote capacity, while also fostering teamwork and collaborating with others.
Minimum of one (1) year of successful experience as a Claims Adjuster or a similar, higher-level role.
Active and valid Property & Casualty (P&C) Adjuster License (or willingness to obtain within a specified timeframe) in good standing.
Bachelor's Degree in Veterinary Science, Business, or a related field -or- Credentialed Veterinary Technician (CVT), Licensed Veterinary Technician (LVT), Registered Veterinary Technician (RVT), or equivalent veterinary experience.

Responsibilities

Manage end-to-end appeals process maintaining strict adherence to regulatory timelines.
Conduct comprehensive reviews of medical records and prior claim history to decide whether to overturn, uphold, or partially overturn original decisions.
Provide clear, concise, and empathetic determination letters to policyholders, ensuring all communications meet internal and regulatory standards.
Communicate directly with policyholders via phone calls and emails to explain appeal determinations and/or answer additional questions.
Act as the liaison to the insurance group and underwriter for escalations, including DOI and BBB complaints, ensuring responses are professional and timely.
Set up and provide detailed written communications regarding legal complaints and attorney inquiries related to claims determinations.
Coordinate with the Insurance Team and underwriter on second appeals and/or escalations.
Serve as a cross-trained resource to assist in Specialty Claims Investigations.
Assist in the audit and referral of high-value claims with invoices exceeding $10,000 to verify medical necessity and policy compliance.
Support the Specialty Team with reassessments, correcting underpayments and overpayments as needed.

Benefits

Comprehensive Medical, dental, and vision plan for you and your family
Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) are available
Highly competitive 401(k) matching
Generous 20-day PTO Policy, with rollover options. Earn an additional day of PTO each year on your anniversary with Fetch, for a maximum of 30 days
Paid company (9) holidays, including (1) floating holiday
Fetch Pet Insurance discount - up to 50% off, up to $1,000 savings/year
Educational Assistance Program
Fetch Discount Perks Program
Volunteering - earn up to 8 hours per calendar year at nonprofit organizations
NYC Office Amenities: Pet-friendly environment, free lunch, snacks, and additional amenities; transit accessible
Employee Referral Incentive
Tuition Assistance
Commuter Benefits
Employee Assistance Program (EAP)