The Company

Aflac Inc.

The Division

Aflac / Premier Life, Absence & Disability

The Location

Remote

Reviews and recommends a course of action on claims elevated after denial of payment; analyzes claims received as a result of volatile, denied, urgent, etc., situations; performs research and analysis to resolve escalated and complex issues relating to claims filed in compliance with insurance laws and regulations

Responsibilities (Principal Duties and Responsibilities)

Reviews, investigates, and evaluates appeals from all lines of business including STD, LTD, Life, PW, ADD, TPA, and Voluntary Products for Fully Insured and Administrative Services Only customers

Completes independent, full, and fair appeal decisions based on Plan/Policy language in a timely manner

Abides by all insurance laws and regulations

Conducts pertinent research to evaluate and respond to appeals

Consults with medical director or obtains independent medical reviews on cases as required by ERISA

Provides timely and detailed appeal determination to the claimant and employer

Performs other related duties as required

Qualifications (Education & Experience and Job Knowledge & Skills)

Education & Experience

Bachelors Degree in Healthcare, Business, or a related field and 10 or more years of combined experience handling appeals from STD, LTD, Life, PW, ADD, TPA, and Voluntary Products for Fully Insured and Administrative Services Only customers, or an equivalent combination of education and experience

Job Knowledge & Skills

Proficient in ERISA regulations including 2018 regulatory changes/requirements

Excellent organization, written and oral communication skills

Experience using MS Office Suite -Word, Excel, and PowerPoint

Excellent presentation and negotiating skills

Advanced skills and comprehensive knowledge of the principles, concepts, practices, and procedures to process claims

Extensive knowledge of all aspects of PLADS products and procedures, policy data, benefit plans, company terminology, medical terminology, and in-house coding systems

Organizational Competencies

Acting with Integrity, Communicating Effectively, Pursuing Self-Development, Serving Customers, Supporting Change, Supporting Organizational Goals, Working with Diverse Populations