PLADS Appeals Consultant in United States at Jobgether

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.

• 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.

• 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.

• 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.