Claims Appeals Specialist

Combined Insurance A Chubb company is seeking aClaims Appeals Specialist to join our fast-paced high energy growing company. We are proud of our tradition of success in the insurance industry of nearly 100 years. Come join our team of hard-working talented professionals!

JOB SUMMARY

The Claims Appeals Specialist is responsible for managing and processing appeals related to insurance claims. This role involves reviewing denied claims analyzing documentation and ensuring compliance with regulatory standards including the Employee Retirement Income Security Act (ERISA) of 1974. The specialist will work closely with insurance claimants healthcare providers Claims and Legal & Compliance teams to resolve disputes and ensure fair outcomes.

RESPONSIBILITIES

• Review and analyze claim decisions to determine the validity of the denial including status and within timeframe expectation.
• Prepare and submit appeal letters and documentation for review.
• Communicate with Claims healthcare providers and claimants to gather necessary information and clarify details.
• Maintain detailed records of appeals and outcomes in the claims management system.
• Ensure compliance with all relevant regulations policies and procedures.
• Monitor appeal deadlines and ensure timely submission of all required documentation.
• Collaborate with other departments to resolve complex claim issues.
• Provide feedback and recommendations for process improvements to reduce claim denials.
• Stay updated on changes in insurance regulations and industry best practices.
• Assist in training and mentoring new team members as needed.
• Support compliance needs and risk audits as needed.
• Assist with incorporation of Compliances interpretation of regulations and laws into Claims processes in a user-friendly way.
• Perform other duties as assigned.

COMPETENCIES

• Problem Solving: Takes an organized and logical approach to thinking through problems and complex complexity by breaking down issues into manageable parts. Looks beyond the obvious to get at root causes. Develops insight into problems issues and situation.
• Continuous Learning: Demonstrates a desire and capacity to expand expertise develop new skills and grow and takes ownership of opportunities to learn acquire new knowledge and deepen technical expertise. Takes advantage of formal and informal developmental opportunities. Takes on challenging work assignments that lead to professional growth
• Initiative: Willingly does more than is required or expected in the objectives on time with minimal and willing to go the extra mile in terms of time and effort. Is self-motivated and seizes opportunities to make a difference.
• Adaptability: Ability to re-direct personal efforts in response to changing circumstances. Is receptive to new ideas and new ways of doing things. Effectively prioritizes according to competing demands and shifting objectives. Can navigate through uncertainty and knows when to change course
• Results Orientation: Effectively executes on plans drives for results and takes accountability for outcomes. Perseveres and does not give up easily in challenging situations. Recognizes and capitalizes on opportunities. Takes full accountability for achieving (or failing to achieve) desired results
• Values Orientation: Upholds and models Chubb values and always does the right thing for the company colleagues and customers. Is direct truthful and trusted by others. Acts as a team player. Acts ethically and maintains a high level of professional integrity. Fosters high collaboration within own team and across the company; constantly acts and thinks OneChubb

SKILLS

• Significant experience working with claims and claimants.
• Excellent verbal and written interpersonal and communication skills.
• Strong understanding of insurance policies and medical records.
• Excellent analytical and problem-solving skills.
• Ability to work independently and manage multiple tasks effectively.
• Detail-oriented with a high level of accuracy.
• Ability to research and solve problems with moderate supervision.

EDUCATION AND EXPERIENCE

• 4-year college degree or equivalency strongly preferred; equivalent work experience may substitute.
• 3 years of experience in claims processing specifically in life accident and health insurance or a related field.
• Experience working with Compliance Risk Management Legal is a plus.
• Proficient in MS Office including Outlook Word Excel & PowerPoint.