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Investigate and audit individual insurance claims to determine liability, process claims per policy, set and adjust reserves, authorize payments, and communicate with TPAs/clients. Escalate large-dollar or trigger-diagnosis cases to case management.
Help us insure itTokio 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 OverviewUnder 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.
- 4 Year / Bachelors Degree Business Administration, a related field, or the equivalent education and/or 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 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)
- 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
- 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
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