Sr Appeals Specialist

Symetra•,

6d•$66,100 - $110,100•Hybrid

About The Position

The Senior Appeals Specialist uses in-depth knowledge of Short Term Disability, Long Term Disability, Life, and Waiver of Premium claims processing to conduct thorough appeals reviews of terminated or denied claims and render appeal decisions. The role follows department guidelines and workflows and adheres to ERISA and other regulatory guidelines and timeframes to reduce the risk of penalties or fines. The specialist also works with Compliance to handle and respond to complaints filed on claims. Appeals work includes reviewing claims against applicable plan or policy provisions, developing and implementing action plans, obtaining information from claimants, representatives, providers, and employers, and requesting appropriate medical or vocational reviews. The specialist determines the type of specialty review needed and develops questions to support accurate decisions, uses tolling and extensions when appropriate, resolves appeals within mandated timeframes, communicates outcomes, and shares trends with management. Complaint work includes coordinating with Compliance on claim-related complaints, maintaining complaint records and communications, researching and compiling supporting information, drafting responses for review by the Compliance Officer and, when appropriate, the Law Department, issuing final responses within required timeframes, and monitoring complaints for follow-up activity. The position offers flexible full-time or hybrid telecommuting arrangements. Symetra describes itself as a remote-first organization and requires employees to meet its specified internet connection standards. Employer work visa sponsorship and support are not provided; applicants must be authorized to work in the United States at hire and maintain that authorization throughout employment.

Requirements

High school diploma or equivalent work experience.
5–8 years of cumulative, relevant experience.

Nice To Haves

College degree.

Responsibilities

Review appealed Short Term Disability, Long Term Disability, or Life claims in accordance with the applicable plan or policy provisions.
Develop action plans for handling appealed claims.
Implement appeal action plans, including contacting claimants or their representatives, providers, and employers to obtain information, and requesting medical or vocational review.
Use tolling and extensions when appropriate during appeal reviews.
Determine the appropriate specialty review, such as vocational or medical review, peer review, IME, Occupational Assessment, or Employability Assessment, and develop questions to support an accurate decision.
Resolve appeals within mandated timeframes and communicate outcomes to appropriate parties.
Identify trends in appeal reviews and communicate them to management for staff development opportunities.
Work with Compliance to handle and respond to claim-related complaints, including complaints filed through state insurance departments and executive or presidential complaints.
Create and maintain records of new and ongoing complaint activity in required systems through resolution and closure.
Maintain communications with appropriate parties regarding complaint activity.
Research and compile data and draft complaint responses with supporting documentation for review by the Compliance Officer and, when appropriate, the Law Department.
Send final complaint responses to appropriate parties within required timeframes.
Monitor complaints for follow-up requests and ongoing activity.