Health Claims Analyst – Stop-Loss & Risk Solutions

Sun Life; Connecticut; Hybrid; USD 54,000 - 81,000; Full time

Job summary

Sun Life U.S. is a leader in employee and government benefit management, serving millions with a broad portfolio of health, life and disability products.

This role focuses on reviewing Stop Loss claims, interpreting contracts, and ensuring documentation supports reimbursements or denials, while mitigating risk and assuring regulatory compliance. The incumbent will manage a block of claims, collaborate with clinical resources, and drive cost containment initiatives, maintaining high quality

Qualifications

• Bachelor's degree preferred.
• 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.

Responsibilities

• Review claims and determine eligibility by applying contractual provisions and medical facts.
• Interpret plan documents and Sun Life contracts for eligibility and exclusions.
• Maintain claim blocks and meet departmental metrics.
• Be aware of industry claim practices and standards.
• Prepare written rationale for claim decisions with documented support.
• Collaborate with internal/external resources (medical, investigative, legal) as needed.
• Establish productive relationships with professional resources to optimize outcomes.

Skills

Healthcare knowledge

Negotiation

Communication skills

Teamwork

MS Office

Travel willingness

Education

Bachelor's degree preferred

Tools

MS Office

Job description

Sun Life U.S. is a leader in employee and government benefit management, serving millions with a broad portfolio of health, life and disability products.

This role focuses on reviewing Stop Loss claims, interpreting contracts, and ensuring documentation supports reimbursements or denials, while mitigating risk and assuring regulatory compliance. The incumbent will manage a block of claims, collaborate with clinical resources, and drive cost containment initiatives, maintaining high quality