Sr Claims Analyst

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:

Location: We support US flexible working arrangements in the contiguous 48 states.  

At Sun Life, we look for optimistic people who want to make life brighter for our  Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America. 

The opportunity: 

• The Health and Risk Solutions Senior Claim Analyst holds the highest technical expertise for a claims unit, including directing the evaluation, investigation, negotiations, and settlement of complex Monthly Accommodations and Individual Specific claims and risk.  Ensures that all legitimate claims and benefits are paid quickly, keeping the interest of both policyholders and the company in proper balance. Effectively manage internal and external relationships.

How you will contribute: 

• Review monthly accommodations advance claims to ensure attachment points and eligible expenses are being processed within the turnaround time goals

• 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.

• Keeps current with industry practices and contributes to evolving claims management techniques. 

• Considered an 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 resolution. 

• Participates in field visits and settlement discussions.

What you will bring with you: 

• 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.

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. 

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