Sr. Claims Analyst, Health and Risk Solutions

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.

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Internal candidates are not required to relocate near an office.

The opportunity: The Health and Risk Solutions Senior Claims Analyst Health and Risk Solutions holds the highest technical expertise for a claims unit including directing the evaluation investigation negotiations and settlement of complex claims and risk. Ensures that all legitimate claims and benefits are paid quickly keeping the interest of both policy owners and the company in proper balance. Effectively manage relationships (internal and external) new hire training as well as coach and mentor to the Health and Risk Solutions Claim Analysts and Overpayment Specialist.

How you will contribute:

• Manages the overall claim risk including the decision to pay/deny a claim by utilizing contract language to develop and implement comprehensive action plans for complex Stop Loss claims.
• Orchestrates the subtleties in the timing of the implementation of complex claims that require sequencing for multiple actions involving multiple parties.
• Recognizes and monitors evolving medical and RX trends and develops responsive case management techniques.
• In depth grasp of highly complex claim practices and legal precedents often presented with unique circumstances requiring precedent-setting solutions.
• Works with peers and management in the department to establish policies and institutionalize it (Brighter Way).
• Manages communications with policyholders administrators top tier brokers sales representatives outside vendors and internal business partners.
• Provides coaching and mentoring develop learning modules for less experienced peers to support their technical and professional development.
• Provide training to new hires on all aspects of reimbursing claims accurately for our clients.
• Manages monthly accommodations advance payments claims
• Keeps current with industry practices and contributes to evolving claims management techniques.
• Considered a leader/expert within the department.
• Uses time management skills to manage an assigned block of claims and maintain a client turnaround time without sacrificing service and supporting the appropriate decision.
• Participates in field visits and settlement discussions.

What you will bring with you:

• Ability to work with a diverse range of people
• Seven (7) plus years of experience handling complex claims preferably in Stop Loss.
• In depth grasp of highly complex claim practices and legal precedents.
• Requires considerable judgment and initiative and makes recommendations which may have influence on company operations.
• Requires a deep understanding of state and federal healthcare legislation and laws as they apply to claims practice and detailed knowledge of most claims practices and accounting.
• Subject matter expert in the industry and has presented to peers or has sat on panels in industry meetings.
• Established network of peers within the industry with which to share ideas and new claim management techniques/processes.
• Communicates effectively negotiates conflict and influences others to take actions not always consistent with their initial objectives.
• Ability to execute complex written correspondence in a manner that meets guidelines and yet is understood by the recipient.
• Works under consultative direction.
• Consistently thinks creatively in developing action plans and arriving at resolutions sometimes using very specialized resources or claims management techniques

Salary:

$68200-$102300

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.