Claims Examiner in Houston, Texas at NEW ERA LIFE INSURANCE COMPANY

Schedule/Shift: Mon-Fri (8am-5pm)

Position Summary
The Claims Examiner is responsible for accurately reviewing and adjudicating health insurance claims in accordance with policy provisions, regulations, and company guidelines. This role involves analyzing medical records and billing codes, interpreting policy language, and ensuring timely and fair claim resolutions while maintaining compliance with industry standards and internal procedures.

Duties and Responsibilities
Claims Review & Adjudication
• Examine medical claims submitted by policyholders, healthcare providers, or their representatives.
• Review medical records, billing codes (CPT, ICD-10), and supporting documentation to verify claim accuracy and legitimacy.
• Interpret policy language and apply benefit provisions to determine coverage.
• Make decisions on claim approvals, denials, or modifications, ensuring fairness and compliance.
Communication & Customer Support
• Communicate claim decisions clearly and professionally to policyholders and healthcare providers.
• Request additional information or clarification from medical providers and policyholders when necessary.
• Collaborate with team members and leadership to resolve complex claim issues efficiently.

Compliance & Quality Assurance
• Ensure adherence to insurance policies, federal and state regulations, and industry standards.
• Stay current with healthcare regulations, company policies, and industry best practices.
• Detect and report potential fraud, abuse, or claim discrepancies.
• Maintain accurate records of claim assessments and decisions for auditing and future reference.

Qualifications and Skills
Required:
• Experience in insurance, healthcare administration, or claims adjudication.
• Strong attention to detail and organizational skills for accurate claim documentation.
• Knowledge of medical procedures, coding systems (CPT, ICD-10), and health insurance billing.
• Ability to analyze data, identify discrepancies, and apply critical thinking to claim decisions.
• Proficiency in claims management systems, medical billing platforms, and Microsoft Office (Word, Excel, Outlook).
• Strong written and verbal communication skills with a professional demeanor.
• Knowledge of healthcare regulations, including HIPAA, and adherence to confidentiality standards.
• Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Legally authorized to work in the United States.
• Ability to successfully pass a background check.

Preferred:
• Post-secondary education in healthcare administration, business, or a related field.
• Experience working in a claims department or within the health insurance industry.

Education
• High School diploma or equivalent (GED)

Work Environment Requirements
• Professional office environment with standard hours (Mon–Fri, 8am–5pm); occasional extended hours during peak times.
• Frequent use of computer, phone, and standard office equipment.
• Regular interaction with staff, leadership, and customers in a fast-paced, high-volume setting.
• Occasional standing, walking, and lifting of up to 15 pounds (e.g., supplies or equipment).