Claims Analyst, Health and Risk Solutions

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

Job Description:

The opportunity: As the leading independent stop loss carrier in the United States, Sun Life is seeking exceptional candidates to join our claims team. 

Stop Loss Claims Analysts are accountable for evaluating claims received, ensuring they are reimbursed correctly and all cost containment opportunities are identified by engaging the clinical team prior to adjudicating a reimbursement.  Providing our clients with outstanding customer service. 

How you will contribute:

• You will own a block of Stop Loss claims and the customer support for your block. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; 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.
• Determine on a timely basis, the eligibility of assigned claims
• Apply appropriate contractual provisions from the underlying policyholder plan, as well as the Sun Life contract, especially with regard to eligibility and exclusions
• Understand where, when and how  resources (both internal and external), e.g. medical, investigative and legal can add value to the process
• Prepare written rationale of claim resolution based on review of the  contract, plan document and the evaluation of medical records
• Maintain  block of business and meet departmental metrics
• Establish cooperative and productive relationships with  internal and external business partners

What you will bring with you:

• Ability to work with a diverse range of people
• Stop Loss Claims and the Stop Loss Insurance industry knowledge
• 3+ years of experience processing medical claims
• Proficiency using MS Office suite
• Bachelors degree or equivalent business experience
• Overall knowledge of the U.S health care industry, including regulatory/statutory guidelines, HIPAA, privacy and the Affordable Health Care Act, as well as a working knowledge of medical terminology and coding (ICD-10, HCPC, etc.)
• An awareness of industry claim practices
• Strong attention to detail
• Excellent written and verbal communication skills
• Capacity to work in a fast-paced environment
• Exceptional customer service skills
• Flexibility to handle multiple priorities while maintaining a high level of professionalism
• Ability to work as part of a cohesive team
• Potential for limited travel

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you!

Life is brighter when you work at Sun Life

• Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
• Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
• A flexible work environment with a friendly, caring, collaborative and inclusive culture
• Great Place to Work® Certified in Canada and the U.S.
• Named as a “Top 10” employer by the Boston Globe's “Top Places to Work” two years running

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.

If you are a California resident, the salary range for this position is:

• Southern region: $57,100-$85,700 annuall