Specific Claims Auditor

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 ResponsibilitiesReview 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 liabilityCommunicate 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.What You Bring4 Year / Bachelors Degree Business Administration, a related field, or the equivalent education and/or experienceStrong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPAAbility to read and interpret documents such as Plan of Benefits, claim reports, and procedural manualsPossess and have ability to apply knowledge of principles, practices, and proceduresSolid written and verbal communication skills with an emphasis on confidentiality, tact, and diplomacyAdvanced organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneouslyKnowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company’s business to proactively respond to changing business environmentIntermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)Additional Working Conditions and Physical DemandsOvertime hours may be required to fulfill job responsibilitiesMay be required to remain stationary for extended periods of timeMay be required to move up to 10 poundsMust be able to operate a computer and other devicesClose vision and ability to adjust focus, such as required to read a computer screenWhat We OfferCompetitive salary and comprehensive benefit packageStrong learning culture with ongoing development opportunitiesOpportunities for growth and career advancementComprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employmentBasic life and disability insurance401(k) plan with 6% company match20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time offPaid parental leaveAccess to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscriptionStudent loan matching programEmployee discount programAn opportunity to do meaningful work and love what you doThe pay range for this position is $40,300-$88,800, 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, citizenship status, genetic information, or any other basis protected by federal, state, or local pay equity laws.The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certai