Senior Specific Claims Auditor

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

Pay Transparency

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, citize