Claims Examiner II at Sutherland

Houston, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

25 Feb, 26

Salary

0.0

Posted On

27 Nov, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Assessment, Policy Interpretation, Benefit Calculation, Customer Communication, Mentorship, Legal Processes, Documentation, Team Collaboration, Insurance Knowledge, Mathematical Calculations, HIPAA Knowledge, Regulatory Knowledge, Microsoft Word, Microsoft Excel, Medical Terminology, Reinsurance Guidelines

Industry

IT Services and IT Consulting

Description

Company Description 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. Job Description 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. Qualifications Education & Experience Associate degree, medical certification, or equivalent work experience required. Minimum 3 years of experience in life/health insurance claims or related field. Experience in life insurance underwriting preferred. Understanding of medical conditions, legal and financial risk factors preferred Certifications (Required Timelines) Completion of industry insurance coursework required after hire: LOMA 281 & LOMA 291 within 12 months ALHC designation within 24 months Technical & Regulatory Knowledge 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.). Additional Information All your information will be kept confidential according to EEO guidelines. EEOC and Veteran Documentation During employment, employees are treated without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status. At times, government agencies require periodic reports from employers on the sex, ethnicity, handicap, veteran and other protected status of employees. The purpose of this Administrative EEO Record is for statistical analysis only and is used to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of the Administrative EEO record is optional. If you choose to volunteer the requested information, please note that all Administrative EEO Records are kept in a Confidential File and are not part of your Application for Employment or Personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

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Responsibilities

The Claims Examiner is responsible for reviewing, evaluating, and making final decisions on various claims. This includes analyzing documentation, communicating with stakeholders, and providing mentorship to junior staff.