Claims Analyst, Health and Risk Solutions

sunlife; Hartford (CT); Hybrid; USD 54,000 - 81,000; Full time

Job summary

Sun Life U.S. in Hartford offers a hybrid work model balancing in-office collaboration with virtual work.

The role reviews Stop Loss claims, interprets contracts, disperses reimbursement and ensures documentation supports the determination, while managing the assigned claim block. You will provide customer service and apply plan provisions, coordinating with clinical resources to manage costs and ensure compliant processing of claims.

Qualifications

• Bachelor's degree preferred.
• Strong written and verbal communication skills.
• Experience with claims or underwriting in a health-care context.

Responsibilities

• Determine, on a timely basis, the eligibility of assigned claim by applying contract provisions and plan specs.
• Apply provisions from the policyholder plan and Sun Life contract for eligibility and exclusions.
• Maintain claim block and meet departmental metrics.
• Maintain awareness of industry claim practices.
• Prepare written rationale of claim decisions based on contract provisions and medical records.
• Understand legal/regulatory guidelines (HIPAA, privacy, ACA) and coordinate with internal/external resources.

Skills

Communication skills

Negotiation

Team collaboration

Underwriting/claims knowledge

Healthcare industry knowledge

Microsoft Office proficiency

Education

Bachelor's degree

Tools

Microsoft Office

Job description

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.

At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

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. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week.

The Opportunity

This position is responsible for reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. You will be responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional 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. The incumbent is accountable for developing, coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources.

What you will do:

• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
• The ability to apply the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the Sun Life contract) especially with regard to eligibility and exclusions
• Maintain claim block and meet departmental metrics
• An awareness of industry claim practices
• Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records
• Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.
• Understand where, when and how professional resources both internal and external, e.g. medical, investigative and legal can add value to the process
• Establish cooperative and productive relationships with professional resources

What you will bring with you:

• Overall knowledge of health care industry
• Demonstrated success in negotiation, persuasion, and solutions-based underwriting
• Ability to work in a fast-paced, high volume environment; flexibility to handle multiple priorities while maintaining a high level of professionalism
• Demonstrated ability to work as part of a cohesive team
• Strong written and verbal communication skills
• Proficiency using the Microsoft Office suite of products
• Ability for occasional travel
• Bachelor's degree preferred

Salary:

Salary Range: $54,100 - $81,200

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 skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life, we prioritize your well-being with comprehensive benefits, inc