Job Description

Position Summary

The Company

Aflac Group

The Division

Customer Assurance Organization

The Opportunity (2 Positions)

Claims Appeal Specialist

The Location

Columbia, SC

Processes claims appeal requests and determines the nature and validity of claims; determines liability and direction of appeals after thorough review of all submitted documentation and verification of policy provisions; approves appeals for final disposition

Responsibilities

Under minimal supervision evaluates claims appeals requests and customer inquiries according to policy provisions and documented claims processing guidelines

Performs duties using knowledge of multiple claim product lines and experience-based judgment to communicate with customers and Aflac personnel; rarely referring specific situations to others unless clarification or interpretation of company policy is involved; communicates customer needs and inquiries to management to provide information for improvement of overall service levels; manages claim risk exposure; reviews and assesses existing work processes and recommends process
improvements/enhancements; serves as subject matter expert on projects/initiatives when assigned

Processes claims appeals and customer inquiries through final disposition based on information submitted for review; analyzes supporting medical or other supporting documentation and uses inhouse claims processing systems that include subsystems for diagnosis and procedures to determine nature and validity of claims; determines liability and direction of appeals after thorough review of all submitted documentation and verification of policy provisions; approves appeals for final disposition,
adhering to specialized department business rules, guidelines, and procedures

Communicates effectively, orally and in writing, in handling the initial processing and follow-up of appeals, and in responding to inquiries from insureds, providers, agents, and attorneys regarding appeal status and policy provisions

Assists in work assigned to the unit, to include reviewing and approving claims, and responding to questions from co-workers; assists with successful transition of new employees to the Claims Appeals Team; escalates more complex situations to the Claims Appeals Coordinators

Composes and/or generates letters to request information or confirm action taken; is responsive and timely with correspondence and problem resolution; coordinates with other departments/divisions as necessary

Consults with supervisor to immediately deliver findings from appeals applicable to adherence to all regulatory requirements and compliance processes

Documents root cause non-conformance issues and performance measures for management review; researches current processes and procedures to assist the division with implementation of concepts to improve processes;

Performs other related duties as required

Qualifications

Education & Experience

High School Diploma or equivalent with 3 years of related work experience or an equivalent combination of education and experience

Job Knowledge & Skills

Knowledge of all aspects of Aflac products and procedures, policy data, benefit plans, company terminology, medical terminology, and in-house coding systems

Knowledge of Aflac systems (e.g., IAAV, HTFM, IIMG, APAY, Group Master, Policy Master, Agent Master, Livelink, Workdesk)

Excellent interpersonal, communication, and customer service skills to effectively interact with Aflac's customers and associates

Excellent comprehension, writing, and grammar skills and strong research, mathematical, and reasoning abilities

Sound organizational skills needed to successfully complete tasks and manage competing priorities

Strong time management skills to prioritize workload, manage numerous tasks, and assist other team members

Knowledge and experience in the cancer skills of initial and follow up claims for all cancer plans, disability due to cancer, wellness, and one or more of the following: LTC, HIP, or HIC, due to cancer and six months of experience as a claims specialist III or above; or

Knowledge and experience in the accident skills of base accident, disability due to accident, wellness, and one of more of the following: accidental death, LTC, HIP, HIC, or SHE due to accident, and six months of experience as a claims specialist III or above; or

Knowledge and experience in the sickness skill of disability and one or more of the following: Vision, LTC, HIP, HIC, or SHE due to sickness and six months of experience as a claims specialist III or above

Organizational Competencies

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

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We will consider for employment all qualified applicants, including those with a criminal history, in a manner consistent with the requirements of all applicable federal, state, and local laws, including the Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and the New York City Fair Chance Act. Applicants with criminal histories are encouraged to apply.

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