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Aggregate Claims Auditor in Kennesaw, GA at Tokio Marine HCC

Date Posted: 9/11/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Kennesaw, GA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    9/11/2018

Job Description

The Stop Loss Group, a member of Tokio Marine HCC, offers an extensive product portfolio including medical stop loss, group term life and long and short-term disability insurance. We provide the self-insured industry with innovative solutions to protect self-funded employers from potentially catastrophic losses.



Position Summary:

 

Under supervision, investigates claims liability and determines the extent of liability on submitted claims for an overall contract that is approaching or exceeds the aggregate attachment point. Accurately processes the claim according to the policies or contracts that exist, within the departmental timeframes and standards, and establishes reserves for claim liability.

 



Key Responsibilities:

 

Relying on limited experience and judgment, the Aggregate Claims Auditor is responsible for accomplishing the following assignments. These assignments are broad in nature and work can be difficult.

 

  • Review and interpret employer plans of health coverage and excess insurance policy.
  • Audit monthly and year-end aggregate claims for payment from receipt through completion. Follow-up on missing documentation when necessary.
  • Interpret paid claims reports, eligibility reports, funding documentation, check registers, prescription reports to verify contract/plan document is being followed correctly.
  • Communicates in writing and verbally with TPA/client as needed to resolve claim processing issues.
  • Set claims reserves and adjusts as needed. Keep the reserves current.
  • Interpret contract/plan document and determine appropriate reimbursement. Also determine any out-of-contract items/amounts.
  • Obtain refunds from TPA when year-end results indicate monthly accommodations were too large.
  • Maintain quality, quantity, and turnaround time standards of company.
  • Review the TPA/client operations to verify in guidelines of contract/plan documents.

Job Requirements



Position Knowledge, Skills, and Requirements:

 

Education

  • Bachelor’s Degree in Business Administration or a related field or the equivalent education and/or experience

 

Experience

  • Minimum of two years of relevant and progressive professional experience

 

Other

  • Possess and have ability to apply broad knowledge of principles, practices, and procedures
  • Strong medical knowledge including ICD10, CPT, medical terminology, COBRA, and HIPPA
  • Ability to read and interpret documents such as Plan of benefits, claim reports, and procedural manuals
  • 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)

Working Conditions and Physical Demands:

  • Overtime hours may be required to fulfill job responsibilities
  • May require travel outside normal work location
  • May require a valid driver’s license
  • May be required to stoop, bend, or sit for extended periods of time
  • May be required to lift up to 10 pounds
  • Dexterity of hands and fingers to operate a computer keyboard, mouse, and other devices
  • Close vision and ability to adjust focus; required to read a computer screen

 

The Tokio Marine HCC Group of Companies offers a competitive salary and employee benefit package. We are 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.

 

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