Aggregate Claims Auditor

Role Description

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 time frames and standards, and establishes reserves for claim liability.

Key Responsibilities

• 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 third-party administrator (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.

Qualifications

• 4 Year / Bachelors Degree Business Administration or a related field or the equivalent education and/or experience.
• 2 Years relevant and progressive professional experience in auditing and claims.
• 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.

Benefits

• Competitive salary and comprehensive benefit package.
• Strong learning culture with ongoing development opportunities.
• Opportunities for growth and career advancement.
• Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment.
• Basic life and disability insurance.
• 401(k) plan with 6% company match.
• 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off.
• Paid parental leave.
• Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription.
• Student loan matching program.
• Employee discount program.
• An opportunity to do meaningful work and love what you do.

Company Description

Tokio Marine HCC is a leading specialty insurance group with offices in the United States, the United Kingdom, Europe, and other exciting locations. With the strength and stability that comes from being a member of the Tokio Marine Group, and more than fifty years of growth, profitability, and stability, we offer important insurance products that most people don’t even know exist. Every policy we write is special, enabling our clients to do amazing things.

For over 50 years, HCC Life Insurance Company, operating as Tokio Marine HCC – A&H Group, has been at the forefront of medical stop loss insurance. In addition to traditional stop loss, we offer captive and Taft-Hartley stop loss solutions, level funded stop loss, Organ & Tissue Transplant insurance and MedPlus insurance. Tokio Marine HCC – A&H Group is rated A++ (Superior) by A.M. Best Company and benefits from the financial stability of its parent company, Tokio Marine HCC.

Applying our Mind Over Risk philosophy to writing insurance allows our customers to take on opportunity with confidence. That philosophy defines our way of thinking, unites us as a team, and differentiates us from our competitors. We are much more than just an insurance company; we are a good company.