Claims Examiner II

Sutherland•Houston, TX

14d

About The Position

The Claims Examiner is responsible for reviewing, evaluating, and making final decisions on life, accidental injury & death, simple annuity, and rider claims. This role requires knowledgeable claim assessment, policy interpretation, benefit calculation, and customer communication. The examiner will approve or deny claims within assigned authority limits, provide mentorship to junior staff, and support continuous improvement initiatives. This position may involve handling claims outside the U.S. and participating in legal processes when necessary.

Requirements

Associate degree, medical certification, or equivalent work experience required.
Minimum 3 years of experience in life/health insurance claims or related field.
Completion of industry insurance coursework required after hire: LOMA 281 & LOMA 291 within 12 months
ALHC designation within 24 months
Strong understanding of life, accident, annuity, and health insurance products.
Knowledge of HIPAA, privacy standards, industry regulations, and Unfair Claims Settlement laws.
Familiarity with insurance and medical terminology.
Proficient in Microsoft Word, Excel, and web-based applications.
Ability to perform mathematical calculations (percentages, interest, etc.).

Nice To Haves

Experience in life insurance underwriting preferred.
Understanding of medical conditions, legal and financial risk factors preferred

Responsibilities

Review, investigate, and adjudicate life, accidental injury & death, simple annuity, and rider claims (including disability waiver and accelerated benefit claims).
Analyze claim documentation, policy contracts, statutory requirements, and determine accurate claim outcomes within authority limits.
Refer claims exceeding authority to senior claims staff.
Calculate benefits and applicable statutory interest.
Communicate with claimants, beneficiaries, legal representatives, and other stakeholders via phone, email, and written correspondence.
Conduct interviews with beneficiaries or next of kin when needed.
Prepare clear written communications, including adverse decision letters.
Provide secondary signature approval and guidance to less-tenured claims examiners.
Interpret insurance policies, contract language, and reinsurance guidelines.
Refer cases to reinsurance when required by treaty terms.
Represent claims department in legal processes if necessary.
Maintain accuracy, compliance, and proper documentation.
Participate in team projects and assist with other claims as assigned.
Support team goals and foster a collaborative environment.