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Appeals Consultant

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Aflac

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Location:
United States

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Category:
Insurance

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Contract Type:
Not provided

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Salary:

75000.00 - 95000.00 USD / Year
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Job Description:

Reviews and evaluates appeal requests for various insurance products, ensuring compliance with regulations and internal policies while supporting a positive customer experience.

Job Responsibility:

  • 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

Requirements:

  • 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)
  • 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
What we offer:
  • 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
  • state-mandated sick leave
  • other leaves of absence

Additional Information:

Job Posted:
February 06, 2026

Expiration:
February 06, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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