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The Role
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.
Summary Generated by Built In
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
Skills Required
- Bachelor's degree in Business Administration or related field, or equivalent education/experience
- Strong medical knowledge including ICD, CPT, and medical terminology
- Knowledge of COBRA and HIPPA/HIPAA regulations
- Ability to read and interpret Plan of Benefits, claim reports, and procedural manuals
- Knowledge and ability to apply claims principles, practices, and procedures
- Solid written and verbal communication skills with emphasis on confidentiality, tact, and diplomacy
- Advanced organizational and analytical skills; ability to manage multiple tasks simultaneously
- Awareness of industry changes, legal updates, and technical developments relevant to the business area
- Intermediate proficiency with Microsoft Office (Excel, Access, PowerPoint, Word)
Tokio Marine Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Tokio Marine and has not been reviewed or approved by Tokio Marine.
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Healthcare Strength — Medical options include established carriers with PPO and HDHP choices, plus dental, vision, pharmacy, telehealth, and condition‑specific programs for comprehensive access. An employee assistance program and mental‑wellbeing resources further reinforce day‑to‑day support.
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Retirement Support — A 401(k) with company match and employer‑paid life and disability coverage strengthen long‑term financial security. Careers materials and recent updates signal continued attention to retirement and protection benefits.
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Wellbeing & Lifestyle Benefits — Wellness incentives, fitness access, and a holistic “body, mind, wallet, life” framework expand total‑rewards value beyond insurance alone. Paid volunteer time and community programs add lifestyle‑oriented benefits aligned with purpose.
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The Company
What We Do
Tokio Marine HCC can help you or your clients be prepared for unpredictable weather patterns. Event weather insurance protects revenue losses caused by adverse weather conditions that reduce attendance and the sales of concessions, food and parking.
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