Specific Claims Auditor

Tokio Marine HCC – A&H Group; United States; On-site; USD 40,000 - 81,000; Full time

Benefits offered by this job

PTO & holidays

401(k) match

Health insurance

Long-term disability

Life insurance

Advancement opportunities

Flexible schedule

Parental leave

Volunteer time off

Casual dress

Free parking

Remote work (GA)

Job summary

Tokio Marine HCC – A&H Group in the United States is seeking a claims professional to investigate liability on individual claims, review health coverage plans, and establish reserves within policy timeframes.

The role requires strong medical knowledge, solid communication skills, and the ability to manage multiple tasks while staying compliant with industry regulations. Eligible for a comprehensive benefits package and a collaborative work environment.

Qualifications

• Strong medical knowledge including ICD, 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.

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.

Skills

Medical knowledge

Reading documents

Application of knowledge

Written & verbal communication

Organization & analytical

Industry updates awareness

MS Office proficiency

Tools

Microsoft Office

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.

Position Summary

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.

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 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 & 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
• 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)

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 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.
• Remote- Georgia

The pay range for this position is $40,300-$80,800, 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.

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 such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.

As an insurance company, we comply with certain federal, state and local laws such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC

• 1033(e)), which restricts our ability to employ individuals with certain types of criminal convictions. Where not restricted by law and for criminal history not covered by this law, 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 such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.

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. For over 50 years, HCC Life Insurance Company, operating as Tokio Marine HCC – A&H Group, has been at the forefront of medical stop loss insurance. In addition to traditional stop loss, we offer captive and Taft-Hartley stop loss solutions, level funded stop loss, Organ & Tissue Transplant insurance and MedPlus insurance. Tokio Marine HCC – A&H Group is rated A++ (Superior) by A.M. Best Company and benefits from the financial stability of its parent company, Tokio Marine HCC. 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.