Determines whether adverse benefit determinations have been properly appealed.Develops and maintains strong working relationships with business partners including, but not limited to, underwriting, sales, actuarial and customer service.Provides appropriate feedback to Claims management and other team members for training purposes.Communicates the decision on appeal thoroughly and accurately in writing to the claimant or his/her authorized representative. Serves as a resource for all Claims personnel regarding the proper adjudication of claims and establishment of best claims practices.Supports the achievement of established departmental goals and objectives related to claim performance including service, quality and production.Ensures the accuracy and timeliness of systems coding for the status of appealed adverse benefit determinations used in management reporting.Reviews, evaluates, and investigates (if necessary) in a timely manner consistent with applicable regulations and company guidelines adverse benefit determinations which have been properly appealed and determine whether the adverse benefit determination was appropriate.Responsible for processing appeals of adverse benefit determinations in all lines of business, which includes Long Term Disability (LTD), Short Term Disability (STD), Life/Waiver of Premium/Group Life products/Accelerated Death/Accidental Death/Critical Illness (and all related coverages) or other claims.
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