Health Claims Analyst - Risk & Stop-Loss Solutions

Sun Life; Wellesley (MA); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Vacation and sick time

401(k) employer match

Medical coverage

Job summary

Sun Life U.S. is seeking a Claims Analyst in Health and Risk Solutions to review and adjudicate Stop Loss claims, interpret contracts, and manage reimbursement decisions.

You will handle customer service and financial risk for an assigned block of claims in a role that balances in-office collaboration with virtual work. The incumbent will apply plan specifications and regulatory guidelines to decide on reimbursements or denials, develop action plans for each claim, and implement cost containment

Qualifications

• Bachelor's degree preferred.
• Strong written and verbal communication skills.
• Proficiency using the Microsoft Office suite of products.
• Ability for occasional travel.
• Ability to work in a fast-paced, high-volume environment; flexibility to handle multiple priorities.

Responsibilities

• 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.
• Apply the contractual provisions from the policyholder and Sun Life contract to eligibility and exclusions.
• Maintain claim block and meet departmental metrics.
• Be aware of industry claim practices.
• Prepare written rationale of claim decisions based on contract provisions and medical records analysis.
• Understand HIPAA, privacy, Affordable Care Act, and related regulatory guidelines.
• Coordinate professional resources (internal and external) to add value to the process.
• Establish cooperative relationships with professional resources.

Skills

Negotiation

Persuasion

Team collaboration

Written and verbal communication

Multi-tasking

MS Office proficiency

Travel flexibility

Education

Bachelor's degree preferred

Tools

MS Office

Job description

Sun Life U.S. is seeking a Claims Analyst in Health and Risk Solutions to review and adjudicate Stop Loss claims, interpret contracts, and manage reimbursement decisions.

You will handle customer service and financial risk for an assigned block of claims in a role that balances in-office collaboration with virtual work. The incumbent will apply plan specifications and regulatory guidelines to decide on reimbursements or denials, develop action plans for each claim, and implement cost containment