Claims Examiner

Who we are:

ManhattanLife Insurance and Annuity Company was founded in 1850, the Company’s longevity makes it one of the oldest and most reliable health and life insurance companies in the country. Operating successfully for 174 years is a testimony to ManhattanLife’s enduring history, and an indicator of the reliability of our future. ManhattanLife’s headquarters are in Houston, TX and the company is continually growing with multiple office locations nation-wide. ManhattanLife offers attractive employee benefits starting day one, including immediate coverage under our health, dental and vision plans. We offer flexible schedules, including shortened hours on Fridays, free parking, company-wide events, professional development (LOMA testing) and a company-wide wellness program.

Scope and Purpose:

We are seeking a Claims Examiner for our Plano, TX office. In the role of Claims Examiner, you will be responsible for the thorough investigation, evaluation, and processing of claims. You will play a critical role in ensuring accurate claim adjudication, timely resolution, and excellent customer service for our clients.

Duties and Responsibilities:

• Review and assess claims to determine coverage, liability, and compensability based on benefit plans, policy provisions, regulatory guidelines, and company protocols.
• Conduct comprehensive investigations into the circumstances surrounding each claim, gathering relevant information, statements, documentation, and evidence as needed.
• Document all aspects of the claims process, including claimant information, incident details, investigative findings, correspondence, and claim disposition, maintaining accurate and detailed claim files.
• Analyze plan coverage and exclusions to determine the extent of eligibility for benefits, interpreting plan document language and applying relevant legal principles to claim decisions.
• Adjudicate claims in accordance with established guidelines, processing payments, denials, or settlements accurately and efficiently while adhering to service level agreements and regulatory requirements.
• Communicate with claimants, employers, brokers, medical providers, and internal departments, such as Account Management and eligibility to gather information, provide updates on claims status and facilitate the resolution of any claims-related issues.
• Coordinate with medical professionals and experts to evaluate medical documentation, treatment plans, and injury claims, ensuring appropriate medical care and cost containment strategies.
• Identify indicators of potential fraud or misrepresentation in claims submission by reviewing claims accurately.
• Conduct regular reviews of claim files to assess accuracy, completeness, and compliance with established company protocols, making recommendations for process improvements as needed.
• Participate in training and team meetings as needed.

Minimum Qualifications:

High School Graduate or equivalent (GED).

Knowledge, Skills and Abilities:

• Prior experience in medical insurance claims examination or related fields is desirable, preferably 5-7 years of experience. TPA experience is preferred.
• Possess experience in using claims management platforms and proficiency in Microsoft Office Suite.
• Strong analytical and problem-solving skills, with ability to convey complex information clearly and professionally to diverse audiences.
• Meticulous attention to detail and accuracy in claim documentation, data entry, and record-keeping to ensure compliance and minimize errors.
• Possess a customer centric mindset with a commitment to delivering high-quality service and resolving claim inquiries and issues effectively.
• Ability to collaborate effectively with peers, supervisors, and executive leadership to achieve common goals and deliver optimal outcomes for clients.
• Adaptability to work in a fast-paced environment, managing multiple priorities and deadlines while maintaining quality and productivity.

Travel Requirements:

This position may require light travel as needed.

• Establish annual objectives for professional growth.
• Keep pace with developments in the discipline.
• Learn and apply technologies that support professional and personal growth.
• Participate in the evaluation process.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle or feel objects, type, and use mouse; reach with hands and arms and talk and/or hear. The employee is required to sit for extended periods of time. The position may require lifting, pulling or moving items weighing upwards of 10 pounds as it relates to office or desk supplies.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee regularly works in an office environment. This role routinely uses standard office equipment such as computers, phones via WebEx, physical phone while in office, and photocopiers when necessary.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to the job at any time without notice.

ManhattanLife prohibits discrimination based on race, religion, gender, national origin, age, disability, veteran status, marital status, pregnancy, gender expression or identity, sexual orientation, or any other legally protected status. EOE Employer/Vet/Disabled. ManhattanLife values differences. We are committed to fostering an environment that attracts and retains a diverse workforce. With individuals from a variety of backgrounds, ManhattanLife will be better equipped to service our customers, increase innovation, and reduce risks. We encourage the unique perspectives of individuals and are dedicated to creating a respectful and inclusive work environment.