Claims Auditor - On Demand

Tokio Marine HCC (TMHCC) brings 50 years of service to the specialty insurance industry, today offering over 100 products to commercial customers in 180 countries around the world.  Organic growth and over 60 successful acquisitions have grown our 2022 Gross Written Premium (GWP) to $5 Billion.  Our workforce has grown to 4,300 worldwide … big, but not so big that you cannot make a difference.  Our Good Company values, including integrity, empowerment, and commitment to customer service, and a culture of innovation, communication, and collaboration make TMHCC a great place to work. 

TMHCC Stop Loss, a $2 Billion division within TMHCC, leads the way in providing medical stop loss insurance sold to employers. Medical Stop Loss provides an added layer of insurance protection to employers who choose to self-fund their health benefit plans. Self-funding can incur risks from catastrophic claims, and Medical Stop Loss insurance from Tokio Marine HCC is designed to protect employers from that risk. 

Position Summary:

Under general 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.

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

• 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 large-dollar claims and trigger diagnosis to preliminary claims unit and specialty claims unit.

Education, Experience & Knowledge:

• 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

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

• 2 Years of relevant and progressive professional experience.

Tokio Marine offers a competitive salary and benefits package, including: 

• Generous paid time off (PTO), 12 paid company holidays,
• 401(k) Retirement Plan with 6% company match.
• Health and dental insurance, and vision plan 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.
• remote role

The Tokio Marine HCC Group of Companies offers a successful, dynamic organization experiencing rapid growth and are seeking energetic and confident individuals to join our team of professionals. The Tokio Marine HCC Group of Companies is an equal-opportunity employer. Please visit www.tmhcc.com for more information about our companies.

#LI-CM3

#stoploss1