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Specialty Claims Nurse (Preferred - Pediatrics and Neonatal) in Kennesaw, GA at Tokio Marine HCC

Date Posted: 9/4/2018

Job Snapshot

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 limited supervision, reviews transplant and neonate cases and implements cost containment measures. Participates in medical underwriting, vendor monitoring and education.

Key Responsibilities:

Relying on limited experience and knowledge, the Specialty Claims Nurse is responsible for accomplishing the following assignments. These assignments are varied in nature.

• Gather in-depth information from sources (physician, providers, U/R vendors, claims and medical records) about an individual’s physical, medical, and psychosocial status. This information will be used in conjunction with the primary case manager to develop a comprehensive case management plan.
• Determine specific objectives and time-specific actions designed to meet the claimant’s needs identified in the assessment phase. At the reinsurance level, this also includes a review of available benefits.
• Organize, secure, and integrate the available resources in order to accomplish the objectives of the case plan.
• Gather relevant information on an on-going basis to determine the plan’s effectiveness and measure cost benefits and set accurate reserves.
• Act as support for renewal underwriting. This includes, but is not limited to, assessing the severity code on on-going claims, adjusting reserves for accuracy, evaluating new referrals if effective within sixty days of notice, and assigning recommended specifics, if requested.
• Educate internal staff and Third Party Administrators about HCCL’s Specialty Claims Unit services.
• Serve as clinical resource for other Medical Underwriting staff based on clinical specialty in transplants.
• Complete projects and other duties as assigned by supervisor.

• Follow work plans, established timelines, and pre-defined goals for assigned work.
• Meet commitments on deadlines.

• Communicate activities, results, and observations with employees and management as appropriate.

Cost Management
• Identify areas for improvement in existing business practices.
• Perform work thoroughly in a cost efficient manner and at a high productivity level.

Business Controls and Policies
• Comply with all corporate policies and procedures.
• Report any breakdowns in controls to management.
• Conduct all activities in a safe manner.

People Management
• No people management responsibility.

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 for more information about our companies.

Job Requirements

Position Knowledge, Skills, and Requirements:

• Registered Nurse, ADN or BSN.

• Minimum of two years of relevant and progressive professional experience

• Strong medical knowledge including ICD, CPT, medical terminology, COBRA, and HIPPA
• 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)


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