Tokio Marine HCC (TMHCC) brings 50 years of service to the specialty insurance industry, today offering over 100 products to commercial customers in 180 countries worldwide.  Organic growth and over 60 successful acquisitions have grown our 2022 Gross Written Premium (GWP) to $5 Billion. Our workforce has grown to 4,300 worldwide … big, but not so big that you cannot make a difference.  Our Good Company values, including integrity, empowerment, and commitment to customer service, and a culture of innovation, communication, and collaboration make TMHCC a great workplace.    TMHCC Stop Loss, a $2 billion division within TMHCC, leads the way in providing medical stop loss insurance sold to employers. Medical Stop Loss provides an added layer of insurance protection to employers who choose to self-fund their health benefit plans. Self-funding can incur risks from catastrophic claims, and Medical Stop Loss insurance from Tokio Marine HCC is designed to protect employers from that risk.    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 claimsAudit submitted claim documents for sufficient data, verifying that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liabilityCommunicate 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 policyRefer large-dollar claims and trigger diagnosis to preliminary claims and case management departments.Follow work plans, established timelines, and predefined goals for assigned work. Education, Experience & Knowledge:Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPAAbility to read and interpret documents such as Plan of Benefits, claim reports, and procedural manualsPossess and have ability to apply knowledge of principles, practices, and proceduresSolid written and verbal communication skills with an emphasis on confidentiality, tact, and diplomacyAdvanced organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneouslyKnowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company’s business to proactively respond to changing business environmentIntermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word) Tokio Marine offers a competitive salary and benefits package including:Generous paid time off (PTO), 12 paid company holidays,401(k) Retirement Plan with 6% company match.Health and dental insurance, vision plan 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.Hybrid work schedule 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. #LI-CM3

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