Specific Claims Auditor

Tokio Marine HCC – A&H Group; United States; On-site; USD 40,300 - 88,800; Full time

Benefits offered by this job

Comprehensive medical, vision, and dental coverage

401(k) plan with 6% company match

20 days PTO and paid parental leave

Access to wellness program

Job summary

Tokio Marine HCC – A&H Group is looking for an Claims Investigator to assess liability on submitted claims and ensure compliance with established policies. You will need strong medical knowledge and communication skills to work effectively with clients and TPA.

The role includes thorough reviewing of claim documents and maintaining accurate records while managing multiple tasks. The position offers a competitive salary ranging from $40,300 to $88,800 depending on experience and geographic location.

Qualifications

• 4-Year/Bachelor's degree in Business Administration or related field.
• Strong medical knowledge including ICD, CPT, and medical terminology.
• Ability to read and interpret documents such as Plan of Benefits.

Responsibilities

• Investigate claims liability and determine the extent of liability.
• Review and interpret employer plans and submitted claim documents.
• Communicate with TPA/client to resolve claim processing issues.

Skills

Medical knowledge (ICD, CPT)

Communication skills

Analytical skills

Organizational skills

Proficiency in Microsoft Office

Education

4-Year/Bachelor's degree in Business Administration or related field

Job description

Role Overview

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 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.
• 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.

What You Bring

• 4‑Year/ Bachelor's degree in Business Administration, a related field, or equivalent education and/or experience.
• 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 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).

Additional Working Conditions And Physical Demands

• Overtime hours may be required to fulfill job responsibilities.
• May be required to remain stationary for extended periods of time.
• May be required to move up to 10 pounds.
• Must be able to operate a computer and other devices.
• Close vision and ability to adjust focus, such as required to read a computer screen.

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.

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.

The Company will consider qualified applicants, including those with criminal histories, in accordance with applicable federal, state, and local laws.

The pay range for this position is $40,300-$88,800, which includes geographic adjustments where applicable.