Bilingual Disability Appeal Specialist

Medavie; United States; Remote; USD 58,000 - 65,000; Full time

Benefits offered by this job

Flexible work arrangements

Health, vision and dental plan (employ

Defined Contribution Pension Plan

Annual Incentive Bonus

Paid vacation and Vacation Purchase

Wellness benefits

Career Growth

Job summary

Medavie is seeking an Appeals Specialist to conduct independent reviews of appealed Life, Disability, and related insurance claims. You will evaluate medical, contractual, administrative, and occupational information to determine appropriate outcomes and provide defensible decision rationales.

As a senior SME, you will coach Claims Examiners and collaborate with medical consultants, legal counsel, and plan sponsors to promote consistency and accuracy in claims management.

Qualifications

• Minimum 5 years of progressive experience in Life and Disability claims adjudication, case management, appeals, or related insurance role.
• Strong ability to interpret contracts, policy provisions, and claims management practices.
• Ability to communicate complex decisions clearly both verbally and in writing.

Responsibilities

• Conduct independent reviews of appealed Life and Disability claims, and related insurance claims.
• Interpret contracts, policy provisions, and internal guidelines to ensure consistent decisions.
• Identify opportunities for quality improvements and support implementation across claims operations.
• Provide guidance to Claims Examiners, Case Managers, Team Leaders, and stakeholders.
• Communicate appeal outcomes and rationale to internal and external partners.

Skills

5+ years claims experience

Education

Post-secondary education in Business Admin / Health Sciences / Nursing / Rehabilitation / Insurance / Law

Job description

Position Type:

Permanent

If you're looking for a fulfilling career that can make a real difference in your life, and the lives of others, you've come to the right place.

As a national health solutions partner, we put people first in everything we do - and that begins with our team of 8,000+ professionals who bring a cross-section of diverse life experiences and career expertise to Medavie. By collaborating and innovating together, our employees are creating industry-leading solutions in insurance, primary care and emergency medical services that impact millions of lives in Canada each year.

Our mission is to improve the wellbeing of Canadians so that every life can be lived to the fullest - and it's reflected in our award-winning culture. We celebrate individuality and value the diverse perspectives and skills our employees contribute. We go beyond providing competitive pay and comprehensive benefits to offer opportunities for personal and professional growth, flexible work options, meaningful experiences, and supportive leadership. Medavie is where employees can be their best selves, feel they belong, and achieve their full potential.

Position Summary

The Appeals Specialist is responsible for conducting comprehensive and impartial reviews of appealed Life, Disability, and associated health-related insurance claim decisions. Acting as a senior subject matter expert, the Appeals Specialist evaluates medical, contractual, administrative, and occupational information to determine whether original claim decisions were appropriate and supported by policy provisions, evidence, and established claims practices.

This role serves as a key quality assurance function within the organization, ensuring consistency, fairness, and accuracy in claim adjudication. The Appeals Specialist provides expert guidance on complex claim matters, identifies opportunities for continuous improvement, and contributes to the enhancement of claims management practices through coaching, trend analysis, and stakeholder collaboration.

What You'll Do

Appeals Review and Decision Making

• Conduct independent reviews of appealed Life, Disability, Critical Illness, Accidental Death & Dismemberment (AD&D), and other related insurance claims.
• Analyze medical, contractual, financial, occupational, and administrative information relevant to appeal decisions.
• Assess the appropriateness and completeness of original claim determinations.
• Render well-reasoned decisions to uphold, modify, or overturn previous claim outcomes.
• Prepare detailed and defensible decision rationales and correspondence.

Contract and Policy Interpretation

• Interpret insurance contracts, policy provisions, administrative agreements, legislative requirements, and internal guidelines.
• Ensure appeal decisions are consistent with contractual obligations, industry standards, and organizational practices.
• Identify and elevate legal, financial, reputational, or compliance risks associated with appeal outcomes.

Quality Assurance and Continuous Improvement

• Review claim handling practices and decision-making processes to identify areas of risk, inconsistency, or opportunity.
• Provide recommendations to improve claims quality, consistency, efficiency, and customer experience.
• Monitor appeal trends and emerging issues and provide insights to leadership and operational teams.
• Participate in audits, special projects, and process improvement initiatives.

Consultation and Coaching

• Act as a subject matter expert for complex Life and Disability claims matters.
• Provide guidance and constructive feedback to Claims Examiners, Case Managers, Team Leaders, and other stakeholders.
• Support the development of best practices, knowledge resources, and training materials.
• Assist in promoting consistency and sound decision-making across claims operations.

Stakeholder Communication

• Communicate appeal outcomes and supporting rationale to internal and external stakeholders in a clear, professional, and respectful manner.
• Collaborate with medical consultants, legal counsel, employers, plan sponsors, reinsurers, and other business partners, as required.
• Respond to inquiries regarding appeal decisions, processes, and policy interpretation.

What You Need to Be Successful

• Post-secondary education in a relevant field such as Business Administration, Health Sciences, Nursing, Rehabilitation, Insurance, Law, or a related discipline.
• Minimum of 5 years of progressive experience in Life and Disability claims adjudication, case management, appeals, or a related insurance role.
• Demonstrated expertise in the interpretation and application of group insurance contracts, policy provisions, and claims management practices.
• Experience assessing complex medical, contractual, financial, and occupational information to support sound claim decisions.
• Strong understanding of Life, Disability, Critical Illness, and Accidental Death & Dismemberment (AD&D) products and claims processes.
• Experience conducting quality assurance reviews, appeals, audits, or complex claim assessments is considered an asset.
• Proven ability to communicate complex decisions and rationale effectively, both verbally and in writing.
• Bilingualism (English and French) is required to perform the duties of the role, which include daily collaboration with teams and partners in Canada who operate in both languages.

We've got you covered!

• Flexible work arrangements and emphasis on work-life balance
• Comprehensive health, vision and dental plan that is 100% employer paid effective on your first day
• 100% employer-matched Defined Contribution Pension Plan
• Annual Incentive Bonus which recognizes your contribution to our success
• Paid vacation and additional Vacation Purchase Program
• Wellness benefits, health resources and fitness center discounts
• Career Growth: We offer a career path encouraging you to follow your passions, learn new skills and focus on growing your career with Medavie.

#CBM1

Pay Range:

$82,648 to $91,831 CAD

This posting is for an existing vacancy within our organization / Ce poste est actuellement vacant au sein de notre organisation.

The Base Pay range may vary depending on the successful candidate or other relevant job-related factors such as knowledge, skills, qualifications, experience and education/training. In addition to Base Pay, eligible Medavie employees may participate in various performance-based incentive programs. Payments under these programs are discretionary and subject to both individual and organizational results.

We believe our employees should reflect the communities we serve and welcome applications from candidates of all backgrounds. To provide the best experience possible, we will support you with accommodations or adjustments at any stage of the recruitment process. Simply inform our Recruitment team of your needs. We are committed to making sure recruitment, retention, advancement, and compensation are fair and accessible while following all relevant human rights and privacy laws_. We appreciate everyone who has shown interest in this position. Only those selected for an interview will be contacted.

While Medavie may use automated tools, including AI, to support application screening, candidates are expected to complete all recruitment interactions independently—without AI assistance—to ensure a fair and equitable process.

If you experience any technical issues throughout the application process, please email: [e-mail].