Specific Claims Auditor

Tokio Marine HCC

5d • $40,300 - $88,800 • Onsite

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

• 4 Year / Bachelors Degree Business Administration, a related field, or the equivalent education and/or experience
• 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.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level