.png){kind=logo}
Investigate and audit individual insurance claims to determine liability, process claims per policy, set and adjust reserves, authorize payments, and communicate with TPAs/clients. Escalate large-dollar or trigger-diagnosis cases to case management.
Help us insure itTokio 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 OverviewUnder 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 claims.
- Audit submitted claim documents for sufficient data, verifying that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
- Communicate 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 policy.
- Refer large-dollar claims and trigger diagnosis to preliminary claims and case management departments.
- 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)
- Overtime hours may be required to fulfill job responsibilities
- May be required to remain stationary for extended periods of time
- May be required to move up to 10 pounds
- Must be able to operate a computer and other devices
- Close vision and ability to adjust focus, such as required to read a computer screen
- 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
Similar Jobs
Insurance
Investigate and audit individual medical stop-loss claims to determine liability, set and monitor reserves, verify benefits paid per plans and policies, authorize payments, refer claims for cost containment, and communicate findings to administrators and clients while ensuring accuracy and timeliness.
Top Skills:
AccessCptExcelIcdPowerPointWord
Insurance
Conduct detailed audits of high-complexity stop-loss claims to ensure accuracy, compliance, and adherence to procedures. Document findings, recommend corrective actions, identify trends, collaborate with departments, and support audit reporting and analytics.
Top Skills:
Audit SystemsExcel
Artificial Intelligence • Machine Learning • Natural Language Processing • Software • Conversational AI
Own the end-to-end product experience for AI coding agents integrating Deepgram: discovery, integration/onboarding, production use, verification, and feedback systems. Build measurement, experimentation, and optimization systems; define agent-specific developer platform requirements and prototype changes; turn agent traffic into rapid product improvements and run cross-functional execution.
Top Skills:
Agent HarnessesCliCloud ApisGitLlmsMcp ServerOn-PremisesReal-Time StreamingSdksSttTtsVoice Agents
What you need to know about the Charlotte Tech Scene
Ranked among the hottest tech cities in 2024 by CompTIA, Charlotte is quickly cementing its place as a major U.S. tech hub. Home to more than 90,000 tech workers, the city’s ecosystem is primed for continued growth, fueled by billions in annual funding from heavyweights like Microsoft and RevTech Labs, which has created thousands of fintech jobs and made the city a go-to for tech pros looking for their next big opportunity.
Key Facts About Charlotte Tech
- Number of Tech Workers: 90,859; 6.5% of overall workforce (2024 CompTIA survey)
- Major Tech Employers: Lowe’s, Bank of America, TIAA, Microsoft, Honeywell
- Key Industries: Fintech, artificial intelligence, cybersecurity, cloud computing, e-commerce
- Funding Landscape: $3.1 billion in venture capital funding in 2024 (CED)
- Notable Investors: Microsoft, Google, Falfurrias Management Partners, RevTech Labs Foundation
- Research Centers and Universities: University of North Carolina at Charlotte, Northeastern University, North Carolina Research Campus
