Senior Specific Claims Auditor

Tokio Marine HCC•Remote - Texas, TX

15d•$56,600 - $125,000

About The Position

Investigates claims liability and determines the extent of liability on a submitted claim for a specific individual. Accurately processes the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establishes reserves for claim liability.

Requirements

Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPA
Ability to read and interpret documents such as Plan of Benefits, claim reports, and procedural manuals
Possess and have ability to apply broad knowledge of principles, practices, and procedures
Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company’s business to proactively respond to changing business environment
Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)

Responsibilities

Review and interpret employer plans of health coverage and excess insurance policy to individual claims.
Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability.
Ability to complete claim review with minimal questions to supervisors.
Able to communicate with external and internal customers in a professional and clear manner.
Monitoring the weekly reserve report consistently.
Monitoring the weekly pend report for timely follow up and accuracy.
Determine, set, monitor reserves to maintain that reserves are appropriate.
Authorize checks for amount of liability and communicate to Claims Administrator/client reasons for any amounts not covered by excess policy.
Refer claims for cost containment to preliminary claims and specialty claims.
Ability to audit complex claims and handle complex processes.
Will be assigned more claims than an auditor, as needed.

Benefits

Competitive salary and comprehensive benefit package
Strong learning culture with ongoing development opportunities
Opportunities for growth and career advancement
Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment
Basic life and disability insurance
401(k) plan with 6% company match
20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off
Paid parental leave
Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription
Student loan matching program
Employee discount program
An opportunity to do meaningful work and love what you do