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 6,400 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.  

Job Description:

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:  

$68,200-$102,300

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