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 6,400 employees and associates in our partner dental practices and operate nationwide.

At Sun Life, we're driven by our

Purpose:

helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

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 in the contiguous states plus AK.

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.

• 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

• 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 of professionalism

• Overall knowledge of health care industry

• Proficiency using the Microsoft Office suite of products

Salary Range: $54,100 -…