Stop Loss & Health Claim Analyst

Sun Life U.S. is one of the largest providers of employee and government benefits helping approximately 50 million Americans access the care and coverage they need. Through employers industry partners and government programs Sun Life U.S. offers a portfolio of benefits and services including dental vision disability absence management life supplemental health medical stop-loss insurance and healthcare navigation. We have more than 6400 employees and associates in our partner dental practices and operate nationwide.

Visit our website to discover how Sun Life is making life brighter for our customers partners and communities.

The Opportunity:

This position is responsible for reviewing claims interpreting and comparing contracts dispersing reimbursement and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. They are responsible for customer service and the financial risk associated with an assigned block of Stop Loss claims. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional case management resources; and claims practices procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim.

The incumbent is accountable for developing coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources.

How you will contribute:

Determine on a timely basis the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
The ability to apply the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the Sun Life contract) especially with regard to eligibility and exclusions
Maintain claim block and meet departmental production and quality metrics
An awareness of industry claim practices
Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records
Knowledge of legal risk and regulatory/statutory guidelines HIPPA privacy Affordable Health Care Act etc.
Understand where when and how professional resources both internal and external e.g. medical investigative and legal can add value to the process
Establish cooperative and productive relationships with professional resources

What you will bring with you:

Bachelors degree preferred
A minimum of three to five years experience processing first dollar medical claims or stop loss claim processing
Demonstrated ability to work as part of a cohesive team
Strong written and verbal communication skills
Knowledge of Stop Loss Claims and Stop Loss industry preferred

Demonstrated success in negotiation persuasion and solutions-based underwriting
Ability to work in a fast-paced environment; flexibility to handle multiple priorities while maintaining a high level ofprofessionalism
Overall knowledge of health care industry
Proficiency using the Microsoft Office suite of products
Ability to travel

Salary Range: $54900 - $82400

At our company we are committed to pay transparency and equity. The salary range for this role is competitive nationwide and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills qualifications experience education and geographic addition to your base salary this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

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We are committed to fostering an inclusive environment where all employees feel they belong are supported and empowered to thrive. We are dedicated to building teams with varied experiences backgrounds perspectives and ideas that benefit our colleagues clients and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life we prioritize your well-being with comprehensive benefits including generous vacation and sick time market-leading paid family parental and adoption leave medical coverage company paid life and AD&D insurance disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match stock purchase options and an employer-funded retirement account. Enjoy a flexible inclusive and collaborative work environment that supports career growth. Were proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S. weve also been recognized as a Top 10 employer by the Boston Globes Top Places to Work for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.

We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans unless the accommodation would impose an undue hardship on the operation of our business. Please email to request an accommodation.

For applicants residing in California please read our employee California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants including those with criminal histories in a manner consistent with the requirements of applicable state and local laws including applicable fair chance ordinances.

All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability or status as a protected veteran.