Specific Claims Auditor
Under general 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.
- 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
- Communicates 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.
Education & Experience
- 4 Year / Bachelors Degree
- Business Administration, a related field, or the equivalent education and/or experience
- 2 years of 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 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
Tokio Marine HCC group of companies offers a competitive salary and employee benefit package. We are 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.