Aggregate Claims Auditor

Help us insure it

Tokio 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.

Role Overview

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

What You Bring

• 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

What We Offer

• 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

The pay range for this position is $50,500-$111,500, which includes geographic adjustments, where applicable. The pay range is the range THMCC, in good faith, believes is the range of compensation for this role at the time of this posting. The hired applicant will be offered pay within the entire range based on the candidate’s geographic location, qualifications, work experience, education, and/or skill level. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of color, race, sex, national origin, sexual orientation, religion, age, veteran status, disability, pregnancy, citizenship status, genetic information, or any other basis protected by federal, state, or local pay equity laws.

The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.] 

As an insurance company, we comply with certain federal, state and local laws such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e)), which restricts our ability to employ individuals with certain types of criminal convictions. Where not restricted by law and for criminal history not covered by this law, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law.

You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if the Company is concerned about a conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction or challenge the accuracy of the background report. The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.]

About Us

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.

Equal Opportunity Employer

TMHCC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, citizenship, color, family or medical care leave, gender identity, genetic information, marital status, medical condition, national origin, physical or mental disability, protected veteran or military status, race, ethnicity, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable local laws, regulations and ordinances.

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