[Hiring] Specific Claims Auditor @Tokio Marine HCC

Role Description

Under supervision, 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.

Key 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 adjust 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.

Qualifications

• Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPAA.
• 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).

Benefits

• Generous paid time off (PTO), 12 paid company holidays.
• 401(k) Retirement Plan with 6% company match.
• Health and dental insurance, and a vision plan are available.
• Company-provided long-term disability and life insurance.
• Opportunities for advancement in a successful and growing organization.
• Flexible work schedules and a great work/life balance.
• Paid Parental Leave.
• Volunteer Time Off.
• Enjoy casual dress and work in a modern, comfortable office with free parking.