Under Claims Examiner

Overview

Job Description Position Summary The U65 Claims Examiner is responsible for reviewing, investigating, and accurately processing Individual health and accident claims. This role handles high-dollar and moderately complex claims, conducts pre-existing and contestability investigations, and ensures all determinations follow policy provisions and regulatory requirements. The Claims Examiner collaborates with department leadership, communicates with internal teams, and maintains accurate, timely claim processing aligned with company standards.

• Claims Review & Processing:
  Review, evaluate, and process Individual health and accident claims in accordance with policy language and established procedures.
• Manage an assigned claim inventory as directed.
• Conduct preexisting condition and contestability investigations as required.
• Maintain and process claims precoded by IT and learn simple processing for Individual Indemnity Plans.
• Technical Claim Evaluation:
  Review and interpret medical records to determine eligibility and benefit application.
• Apply working knowledge of insurance and medical terminology.
• Develop foundational understanding of ICD
  10, CPT, and HCPCS coding (advanced knowledge considered a plus).
• Evaluate high-dollar and certain complex claims with attention to accuracy and compliance.
• Compliance & Documentation:
  Ensure claims are processed in accordance with HIPAA, the Affordable Care Act, and other applicable state and federal regulations.
• Maintain accurate documentation of claim decisions and investigative steps.
• Support audit readiness and ensure adherence to internal quality standards.
• Communication & Coordination:
  Coordinate with Claims leadership and other Claims units to ensure consistent handling of claim issues.
• Collaborate with other internal departments to support efficient information flow and strong interdepartmental communication.
• Respond to internal inquiries and support resolution of issues related to claim processing.
• Team Support & Administrative Responsibilities:
  Participate in departmental initiatives, training, and workflow improvements.
• Maintain assigned work schedules, production expectations, and accuracy standards.
• Perform other duties as assigned by management.

Required:

• 35 years of experience managing complex or high-dollar health claims, preferably within Individual health insurance.
• Ability to interpret medical records and apply policy language accurately.
• Strong written and verbal communication skills.
• High attention to detail, strong organizational skills, and the ability to manage multiple priorities.
• Knowledge of insurance and medical terminology.
• Self-motivated, resilient under pressure, and able to learn quickly.
• Legally authorized to work in the United States.
• Ability to successfully pass a background check.

Preferred:

• Prior experience with Individual Indemnity Plans.
• Basic knowledge of ICD
  10, CPT, and HCPCS coding systems.
• Proficiency in claims systems and Microsoft Office applications (Word, Excel, Outlook).

• High School diploma or equivalent (GED) required.

• Professional office environment.
• 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 10 pounds (e.g., supplies or equipment).
• Hybrid or remote work options may be available, depending on business needs and company policy.

Houston, TX — Full Time