Senior Claims Auditor
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Job Description
Investigating claims liability and processing claims for Tokio Marine HCC. Ensuring compliance with health coverage policies within departmental standards.
Responsibilities:
- 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
- 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
Requirements:
- 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)
Benefits:
- 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
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