Specific Claims Auditor
HCC Insurance Holdings, Inc. - Kennesaw, GA

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Position Summary: Under general supervision, investigate claims liability and determine the extent of liability on a submitted claim for a specific individual. Accurately process the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establish reserves for claim liability.

Key Responsibilities:

Relying on experience and judgment, the Specific Claims Auditor is responsible for accomplishing the following assignments. These assignments are broad in nature and work can be difficult.
  • Review and interpret employer plans of health coverage and excess insurance policy to individual claims.
  • Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
  • Communicates in writing and verbally with 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.

Planning
  • Develop work plans, establish timelines, and set goals for assigned work.
  • Meet commitments on deadlines.

Communication
  • Review activities, results, and recommendations with management and clients as appropriate.
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Cost Management
  • Drive improvement in existing business processes.
  • Perform work thoroughly in a cost efficient manner and at a high productivity level.

Business Controls and Policies
  • Comply with all corporate policies and procedures.
  • Report any breakdown in controls to management.
  • Conduct all activities in a safe manner.

People Management
  • No people management responsibility but may provide guidance to less experienced employees

Requirements

Position Knowledge, Skills, and Requirements:

Education
  • Associate’s degree in Business Administration or a related field or the equivalent education and/or experience

Experience
  • Minimum of five years of relevant and progressive professional experience

Other
  • Possess and have ability to apply broad knowledge of principles, practices, and procedures
  • Strong medical knowledge including ICD, CPT, medical terminology, COBRA, and HIPPA
  • Ability to read and interpret documents such as Plan of benefits, claim reports, and procedural manuals
  • Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
  • Exceptional 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)

HCC Insurance Holdings, Inc. - 21 months ago - save job