New Era Life Insurance Companies ยท 1 week ago
U65 Senior Claims Examiner
Houston, TX
Full-time
Hybrid
Senior Level
5+ years expNew Era Life Insurance Companies is seeking a Senior Claims Examiner responsible for reviewing, analyzing, and adjudicating complex medical claims. This role requires expertise in policy interpretation and medical coding, ensuring compliance with regulatory standards while collaborating with various departments.
Insurance
Responsibilities
Review, investigate, and adjudicate high-dollar, escalated, or complex Individual health claims
Interpret and apply policy contract language, endorsements, exclusions, and benefit limitations accurately
Analyze medical records, billing statements, and supporting documentation to determine medical necessity and benefit eligibility
Apply advanced knowledge of ICD10, CPT, and HCPCS codes in determining proper claim outcomes
Identify questionable coding or billing practices and escalate when appropriate
Evaluate fraud indicators and refer cases to SIU or management as needed
Ensure all claim determinations comply with state and federal regulations, including HIPAA and ACA requirements
Maintain high standards of documentation accuracy for audit readiness
Participate in quality reviews and contribute to continuous improvement efforts
Work closely with other Claims units, Underwriting, Customer Service, and other internal departments to resolve issues efficiently
Communicate promptly and professionally with internal stakeholders regarding claim status, decisions, or exceptions
Provide guidance to Claims Examiners regarding complex scenarios or policy interpretation
Support training and development of new or junior examiners
Share expertise and contribute to cross-training initiatives within the department
Assist leadership with projects, reporting, or workflow improvements as requested
Qualification
Required
57 years of claims experience, including complex or highdollar medical claims (Individual insurance experience preferred)
Strong knowledge of medical terminology, coding (ICD10, CPT, HCPCS), and healthcare billing practices
Ability to read, analyze, and interpret medical records
Excellent written and verbal communication skills
High attention to detail with strong analytical and organizational skills
Ability to work independently, meet deadlines, and manage competing priorities
Proficiency in claims management systems and Microsoft Office tools
Legally authorized to work in the United States
Ability to successfully pass a background check
Preferred
Experience with Individual Indemnity products or supplemental health plans
Prior mentoring or team lead experience
Familiarity with state and federal regulatory requirements impacting health claims
Company
New Era Life Insurance Companies
The company was founded in 1989 by Dr. Bill Chen, CEO and Founder of New Era.
51-200 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase