Specific Claims Auditor

Tokio Marine HCC

Claims Auditor reviewing and interpreting employer health coverage plans and submitting claims. Investigating claims liability and ensuring compliance with appropriate policies and plans.

Posted 6/20/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $40,300 - $88,800 per yearWebsite

About the role

Key responsibilities & impact

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
Establishes reserves for claim liability
Reviews and interprets employer plans of health coverage and excess insurance policy to individual claims
Audits submitted claim documents for sufficient data, verifying that benefits were paid correctly and in accordance with appropriate plans and policies
Communicates in writing and verbally with third-party administrator (TPA)/client, as needed, to resolve claim processing issues
Sets claims reserves and adjusts as needed
Keeps the reserves current
Authorizes checks for amount of liability and communicates to TPA/client reasons for any amounts not covered by excess policy
Refers large-dollar claims and trigger diagnosis to preliminary claims and case management departments

Requirements

What you’ll need

4 Year / Bachelors Degree Business Administration, a related field, or the equivalent education and/or experience
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)

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims liability investigationclaims processingclaims reserves establishmentclaims auditingmedical terminologyInternational Classification of Diseases (ICD)Current Procedural Terminology (CPT)COBRAHIPAAanalytical skills

Soft Skills

written communicationverbal communicationconfidentialitytactdiplomacyorganizational skillsability to manage multiple tasks