Specific Claims Auditor

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. 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. 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 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.