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Specific Claims Auditor in Santa Ana, CA at Tokio Marine HCC

Date Posted: 7/25/2018

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.

We have an exciting opportunity for a Specific Claims Auditor in our office in Santa Ana, CA.

Position Summary:

Under general supervision, investigate claims liability and determine the extent of liability on a submitted claim for a specific individual. Accurately process the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establish reserves for claim liability.

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

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
  • 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.
  • 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.

Job Requirements

Education:

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

Experience:

  • Minimum of three to five years of relevant and progressive professional experience
  • Strong medical knowledge including ICD, CPT, medical terminology, COBRA, and HIPPA
  • Ability to read and interpret documents such as Plan of benefits, claim reports, and procedural manuals

 

 Other:

  • 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)

 

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.