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Investigates individual claims to determine liability under health coverage and excess insurance plans. Reviews claim documentation, verifies benefit payments, establishes and updates reserves, authorizes liability checks, communicates with third-party administrators and clients, and explains uncovered amounts. Refers high-value claims and trigger diagnoses to appropriate departments. Requires medical terminology and coding knowledge, strong analytical and organizational skills, confidentiality, communication abilities, and proficiency with Microsoft Office.
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.Position Summary:Under 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 Responsibilities:
- Review 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 liability
- Communicate 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.
- 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 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)
- Generous paid time off (PTO), 12 paid company holidays,
- 401(k) Retirement Plan with 6% company match.
- Health and dental insurance, and a vision plan are available.
- Company-provided long-term disability and life insurance.
- Opportunities for advancement in a successful and growing organization.
- Flexible work schedules and a great work/life balance.
- Paid Parental Leave.
- Volunteer Time Off.
- Enjoy casual dress and work in a modern, comfortable office with free parking.
- Remote- Georgia
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