Stop Loss & Health Claim Analyst

Stop Loss & Health Claim Analyst

Sun Life U.S. is one of the largest providers of employee and government benefits, serving approximately 50 million Americans. Through employers, industry partners and government programs, Sun Life offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop‑loss insurance, and healthcare navigation.

This position is responsible for reviewing stop‑loss claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring accurate claim determination. The analyst provides customer service, manages the financial risk for an assigned block of stop‑loss claims, and applies contractual provisions and plan specifications to medical facts to decide on reimbursement or denial.

• Determine the eligibility of assigned claims by applying the appropriate contractual provisions to the medical facts and plan specifications.
• Apply contractual provisions from both the underlying plan and the Sun Life contract, especially regarding eligibility and exclusions.
• Maintain claim block and meet departmental production and quality metrics.
• Prepare written rationale for claim decisions based on contractual provisions, plan specifications, and analysis of medical records.
• Understand and navigate regulatory, statutory, and HIPAA privacy guidelines.
• Coordinate with professional resources (medical, investigative, legal) to add value to the claims process.
• Establish cooperative relationships with professional resources.

• Bachelor’s degree preferred.
• Three to five years’ experience processing first-dollar medical claims or stop‑loss claim processing.
• Strong written and verbal communication skills.
• Knowledge of stop‑loss claims and industry preferred.
• Demonstrated success in negotiation, persuasion, and solution-oriented underwriting.
• Ability to work in a fast‑paced environment and handle multiple priorities.
• Overall knowledge of the health‑care industry.
• Proficiency with Microsoft Office suite.
• Willingness to travel as required.

Salary Range: $54,900 – $82,400 annual base. This position is eligible for a discretionary annual incentive award based on individual and business performance.

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.

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

We will make reasonable accommodations for qualified individuals with disabilities or special disabled veterans. For accommodations, please contact