Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.

A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.

Great Place to Work®

Most Loved Workplace®

Forbes Best-in-State Employer

Appeals Specialist Sr.

Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence:

Dubuque, IA : 4141 Westmark Drive, Dubuque, IA 52002

Cedar Rapids, IA : 333 1st Street SE Ste. 200 Cedar Rapids IA 52401

Coralville, IA: 3273 Ridgeway Drive Coralville IA 52241

Dublin, OH : 5500 Glendon Court Dublin OH 43016

New Albany, OH : 7795 Walton Parkway New Albany, OH 43054

Chicago, IL : 175 W. Jackson Blvd. 12th Fl. Chicago IL 60604

Indianapolis, IN: 8909 Purdue Road Suite 501 Indianapolis, IN 46268

Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063

Memphis, TN : 8125 Sedgwick Way, Memphis TN 38125

Southfield, MI : 300 Galleria Officentre Southfield MI 48034

Orlando, FL : 12650 Ingenuity Dr Orlando FL 32826

Eden Prairie, MN : 11000 Prairie Lakes Drive Eden Prairie, MN 55344

West Hills, CA : 8521 Fallbrook Ave West Hills, CA 91304

PRIMARY PURPOSE : Analyzes disability claims, approves client communications, and ensures the integrity of the claim appeal process. The Appeals Specialist Senior provides guidance and mentorship to colleagues on the claims appeal process.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Reviews disability and companion claims, providing guidance and assistance to colleagues through the appeals process.

• Analyzes and approves communications to client and claim operation summarizing the appeal review determination.

• Facilitates training to the claim operation regarding the claim appeal process.

• Ensures integrity of the claim appeal process and ensures compliance with the Employee Retirement Income Security Act of 1974 (ERISA) legislation.

• Ensures appeal requests are managed timely and follow the ERISA regulations or client plans; ensures accurate appeal decisions are made by the appeals specialists.

• Identifies areas to minimize risk of fines, penalties, or errors and omissions and makes recommendations for improvements.

• Reviews medical documentation and provides clinical and claim expertise on appealed claims.

• Monitors third party claims; maintains periodical review of litigated claims, serious vocational rehabilitation claims, questionable claims and sensitive claims as determined by client.

• Owns unique or critical lines of business such as, but not limited to, long term disability, paid family medical leave, and voluntary.

• Manages ad hoc departmental programs and spearheads multi-stakeholder projects group-wide processes as needed.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing

Bachelor's degree from an accredited college or university preferred. State licensing required within six months of starting the role, as appropriate.

Experience

Six (6) years of related experience, to include experience reading and interpreting policy and medical terms, or equivalent combination of education and experience required.

Skills & Knowledge

• Strong knowledge of ERISA regulations

• Thorough knowledge of claims processes for multiple lines of business

• Ability to work independently and with autonomy

• Ability to solve difficult and complex problems based on analysis, experience, and judgement

• Excellent oral and written communication skills, including presentation skills

• PC literate, including Microsoft Office products

• Analytical and interpretive skills

• Strong organizational skills

• Ability to create and complete comprehensive, accurate and constructive written reports

• Ability to work in a team environment

• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental : Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical : Computer keyboarding, travel as required

Auditory/Visual : Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $ 55,671.00 - $85,000.00 USD Annual . A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Taking care of people is at the heart of everything we do. Caring counts

Sedgwick is a leading global provider of technology-enabled risk, benefits and integrated business solutions. Every day, in every time zone, the most well-known and respected organizations place their trust in us to help their employees regain health and productivity, guide their consumers through the claims process, protect their brand and minimize business interruptions. Our more than 30,000 colleagues across 80 countries embrace our shared purpose and values as they demonstrate what it means to work for an organization committed to doing the right thing – one where caring counts. Watch this video to learn more about us. (https://www.youtube.com/watch?v=ywxedjBGSfA)