Aggregate Claims Auditor

Tokio Marine HCC

Aggregate Claims Auditor at Tokio Marine HCC investigating claims liability and processing according to defined policies. Requires bachelor's degree and 2 years experience in auditing and claims.

Posted 7/14/2026full-timeRemote • 🇺🇸 United StatesJuniorMid-Level💰 $50,500 - $111,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims investigation, liability assessment, and auditing processes while maintaining compliance with health coverage policies and regulations. Proficient in interpreting complex documents and communicating effectively with clients and third-party administrators.

Highest-signal resume keywords

Claims InvestigationICD10 Medical CodingCPT Medical CodingAuditing ExperienceStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingLiability AssessmentMedical TerminologyPlan Document InterpretationClaims Reserve ManagementAnalytical SkillsOrganizational SkillsDocumentation ReviewRefund ProcessingAggregate Claims Auditing

Soft Skills

Written CommunicationVerbal CommunicationConfidentialityTactDiplomacy

Industry Keywords

Health CoverageExcess Insurance PolicyCOBRAHIPAAEligibility ReportsFunding DocumentationCheck RegistersClaims ReportsEmployer PlansThird-Party Administrator

About the role

Key responsibilities & impact

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
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

Requirements

What you’ll need

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

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
Opportunities for growth and career advancement