Specific Claims Auditor

Tokio Marine HCC•Remote - Georgia, GA

1d•Remote

About The Position

Under supervision, investigates claims liability and determine 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 knowledge of principles, practices, and procedures
Solid written and verbal communication skills with an emphasis on confidentiality, tact, and diplomacy
Advanced 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, verifying that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability.
Communicate in writing and verbally with third-party administrator (TPA)/client, as needed, to resolve claim processing issues.
Set claims reserves and adjusts as needed. Keep the reserves current.
Authorize checks for amount of liability and communicate to TPA/client reasons for any amounts not covered by excess policy.
Refer large-dollar claims and trigger diagnosis to preliminary claims and case management departments.