PLADS Appeals Consultant

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a PLADS Appeals Consultant based in United States.

This role sits at the intersection of claims analysis, regulatory compliance, and customer advocacy within a highly structured insurance environment. The Appeals Consultant is responsible for reviewing complex disability and life benefit appeals, ensuring decisions are accurate, well-documented, and fully compliant with ERISA and other applicable regulations. You will analyze medical, vocational, and policy-related information to support fair and timely determinations that directly impact claimants and employers. The role requires close collaboration with clinical experts, legal teams, and internal stakeholders to resolve high-complexity cases. It is a detail-driven position that demands strong analytical thinking, disciplined documentation, and sound judgment. This is an opportunity to contribute to a mission-driven organization focused on delivering reliable financial protection when people need it most.

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Accountabilities:

• Review and evaluate appeal requests across disability, life, and supplemental insurance products, ensuring compliance with policy provisions and regulatory requirements.
• Conduct comprehensive analysis of claim files, medical records, vocational data, and policy documentation to support fair and accurate appeal decisions.
• Ensure all determinations align with ERISA regulations, state laws, and internal compliance standards.
• Perform detailed research to interpret plan provisions and resolve complex case questions.
• Collaborate with medical directors, legal advisors, clinical experts, and other stakeholders to assess complex or high-risk cases.
• Document all findings, rationale, and decisions clearly within claim management systems for audit and reporting purposes.
• Communicate appeal outcomes in a clear, professional, and empathetic manner to claimants, employers, and partners.
• Manage assigned caseload efficiently to meet productivity, quality, and regulatory deadlines.
• Identify cases requiring escalation due to complexity, risk, or policy interpretation challenges.
• Support continuous improvement of claims processes and contribute to a positive customer experience.

Requirements:

• Bachelor’s degree in healthcare, business, or a related field, or equivalent combination of education and experience.
• 5+ years of experience in disability, life, or group benefits claims, with direct involvement in appeals or complex claim reviews.
• Strong knowledge of ERISA regulations, including recent updates and compliance requirements.
• Experience with STD, LTD, Life, AD&D, waiver of premium, TPA, and voluntary benefit products.
• Familiarity with regulated insurance environments, including state and federal compliance frameworks.
• Strong analytical skills with the ability to interpret medical, vocational, and technical documentation.
• Excellent written and verbal communication skills, with strong attention to documentation accuracy.
• Proficiency in claim management systems and Microsoft Office tools.
• Ability to manage workload independently while maintaining quality and compliance standards.
• Strong interpersonal skills and ability to collaborate with clinical, legal, and operational teams.

Benefits:

• Competitive annual salary ranging from $75,000 to $95,000 depending on experience and location.
• Comprehensive medical, dental, and vision insurance coverage.
• Health savings and flexible spending account options, including dependent care FSA.
• 401(k) retirement savings plan with employer participation.
• Paid time off, including up to 20 days annually, plus 11 paid holidays.
• Supplemental insurance coverage options (accident, critical illness, hospital indemnity, etc.) at low or no cost.
• Annual bonus eligibility and employee stock purchase opportunities.
• Fully remote work within the United States, with occasional travel (up to 10%) if required.

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How Jobgether works:

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

 Why Apply Through Jobgether? 

Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.

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