Appeals Specialist Sr.

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.