Senior Specific Claims Auditor

Tokio Marine HCC – A&H Group; Minnesota; On-site; USD 56,600 - 125,000; Full time

Benefits offered by this job

Competitive salary

401(k) match

Paid time off (PTO)

Medical coverage

Wellness program

Job summary

Tokio Marine HCC is seeking a Claims Auditor to investigate liability on submitted health and excess claims. You will review plans, audit documentation, and determine reserves within policy guidelines, communicating findings professionally to clients and internal teams.

The role requires strong medical knowledge (ICD, CPT, HIPAA), excellent communication, and rigorous attention to accuracy across multiple claims experiences. Join a leading specialty insurer and contribute to accurate reserving.

Qualifications

• Strong medical knowledge including ICD, CPT, and HIPAA
• Ability to read Plan of Benefits and claims reports
• Excellent written and verbal communication; confidentiality and diplomacy

Responsibilities

• Review employer health coverage and excess policy to determine liability for individual claims
• Audit submitted claim documents for data sufficiency and verify benefits paid
• Monitor weekly reserve and pend reports for accuracy and timely follow-up
• Determine, set and monitor reserves to ensure adequacy
• Authorize checks for liability amounts and communicate reasoning to clients and claims team
• Audit complex claims and handle complex processes
• Assist with higher claim assignments as needed

Skills

ICD knowledge

CPT knowledge

Medical terminology

HIPAA compliance

Communication skills

Analytical skills

Office software

Tools

Microsoft Excel

MS Access

PowerPoint

Word

Job description

Help us insure it

Tokio Marine HCC is a global industry-leading specialty insurance group, backed by the strength and stability of the Tokio Marine Group. Offering over 100 classes of specialty insurance, we empower clients to pursue opportunities confidently through our “Mind Over Risk” philosophy. More than an insurance company, we are an organization built on innovation, unity, and trust.

At our core, we are Always Advancing, driven by innovation and an entrepreneurial spirit that keeps us moving forward. Our people are Experts in Tomorrow, using curiosity and smart working to anticipate what’s next. With a culture rooted in Reaching Out, we foster genuine collaboration and support, ensuring every individual has the opportunity to succeed and make a difference.

Role Overview

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, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability.
• Ability to complete claim review with minimal questions to supervisors
• 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 claims for cost containment to preliminary claims and specialty claims.
• Ability to audit complex claims and handle complex processes.
• Will be assigned more claims than an auditor, as needed.

What You Bring

• 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
• Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)

What We Offer

• Competitive salary and comprehensive benefit package
• Strong learning culture with ongoing development opportunities
• Opportunities for growth and career advancement
• 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
• An opportunity to do meaningful work and love what you do

The pay range for this position is $56,600-$125,000, which includes geographic adjustments, where applicable. The pay range is the range THMCC, in good faith, believes is the range of compensation for this role at the time of this posting. The hired applicant will be offered pay within the entire range based on the candidate’s geographic location, qualifications, work experience, education, and/or skill level. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of color, race, sex, national origin, sexual orientation, religion, age, veteran status, disability, pregnancy, citizenship status, genetic information, or any other basis protected by federal, state, or local pay equity laws.

California → Use CA Fair Chance language.

The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law.

You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if the Company is concerned about a conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction or challenge the accuracy of the background report. The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law.

About Us Tokio Marine HCC is a leading specialty insurance group with offices in the United States, the United Kingdom, Europe, and other exciting locations. With the strength and stability that comes from being a member of the Tokio Marine Group, and more than fifty years of growth, profitability, and stability, we offer important insurance products that most people don’t even know exist. Every policy we write is special, enabling our clients to do amazing things.

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.

Applying our Mind Over Risk philosophy to writing insurance allows our customers to take on opportunity with confidence. That philosophy defines our way of thinking, unites us as a team, and differentiates us from our competitors. We are much more than just an insurance company; we are a good company.

Equal Opportunity Employer

TMHCC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, citizenship, color, family or medical care leave, gender identity, genetic information, marital status, medical condition, national origin, physical or mental disability, protected veteran or military status, race, ethnicity, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable local laws, regulations and ordinances.

#stoploss1