Claims Investigation Services Senior Consultant

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.

The Senior Consultant, Claims Investigation Services (CIS) is responsible for department quality control and audit responsibilities in addition to leading complex investigations involving suspected fraud, abuse, misrepresentation, provider misconduct, and other irregular claim activity across Sun Life U.S. Supplemental Health products, including Accident, Critical Illness, Cancer and Hospital Indemnity.

• Serve as the subject matter expert for Supplemental Health fraud investigations.
• Train claims professionals to identify fraud indicators and escalation triggers.
• Provide consultation and guidance on suspicious claims.
• Develop investigation playbooks, reference materials, and best practices.
• Foster awareness of fraud risks across Claims Operations.

• Bachelor's degree or equivalent experience.
• Strong analytical and problem-solving skills.
• Experience reviewing medical records and claim documentation.
• Ability to conduct complex investigations independently.
• Strong written and verbal communication skills.
• Experience presenting findings to senior leadership.

• Lead investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, or organized fraud schemes.
• Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information, and payment history.
• Analyze claim activity to identify unusual patterns, trends, or indicators of fraud.
• Develop and execute investigation plans based on risk, complexity, and financial exposure.
• Determine appropriate investigative actions and escalation paths.
• Document investigative findings, recommendations, and outcomes.

• Conduct quality audits of staff-processed claims to ensure consistent and accurate application of claim department guidelines, procedures, policy provisions, and benefit adjudication standards.
• Identify quality trends, error patterns, process gaps, and coaching opportunities that may impact claim accuracy, timeliness, member experience, or operational consistency.
• Provide audit findings, feedback, and recommendations to Claims Operations leaders to support staff development, procedural alignment, and continuous improvement.
• Maintain audit documentation and reporting to support quality control oversight, management review, and adherence to internal claim handling requirements.

• Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies.
• Identify high-risk claims through:
  • Claims frequency analysis
  • Repeat provider patterns
  • Repeat member behavior
  • Injury and diagnosis trends
  • Geographic anomalies
  • Payment concentration analysis
• Prioritize investigation inventory using risk-scoring methodologies.
• Quantify financial exposure and recoverable amounts.
• Identify emerging fraud schemes and recommend mitigation strategies.

• Coordinate medical record procurement and evidence gathering activities.
• Validate submitted documentation against provider records.
• Evaluate claim eligibility, diagnosis validity, treatment patterns, and supporting evidence.
• Identify inconsistencies between claim submissions and medical records.
• Work with internal clinical resources as necessary to assess medical appropriateness and validity.

• Partner with Legal, Compliance, Risk Management, and SIU to ensure investigations comply with applicable laws and regulations.
• Prepare investigation summaries and supporting materials for internal and external reviews.
• Support regulatory inquiries, audits, legal proceedings, and fraud reporting requirements.
• Maintain investigation documentation consistent with company protocols and legal requirements.

• Develop proactive fraud prevention strategies for Supplemental Health.
• Identify process vulnerabilities that may enable fraudulent activity.
• Recommend…