Hybrid Health Claims Analyst — Stop-Loss & 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. 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.