Hybrid Health Claims Leader

Careerwebsite; Milwaukee (WI); Hybrid; USD 68,000 - 102,000; Full time

Benefits offered by this job

Discretionary bonus

401(k) match

Generous vacation/sick time

Medical coverage

Job summary

Sun Life U.S. embraces a hybrid work model balancing in-office collaboration with virtual work across contiguous states plus AK.

The Senior Claim Analyst leads complex claim evaluation, investigation, negotiation, and settlement to ensure accurate payments while balancing policy owners and company interests. You will mentor analysts, support training, and develop claim policies, coordinating across brokers, administrators, and internal partners to drive best practices in a high-stakes

Qualifications

• 7+ years of experience handling complex claims, Medical Stop Loss or complex Medical Claims.
• Deep knowledge of complex claim practices, legal precedents, claims accounting, and applicable state and federal healthcare legislation.
• Strong judgment, initiative, and consultative decision-making, with the ability to influence recommendations.

Responsibilities

• Manage overall claim risk, including pay/deny decisions, by applying contract language and developing action plans for complex Stop Loss claims.
• Coordinate complex claims activity across multiple parties, ensuring actions are appropriately sequenced and completed on time.
• Identify and monitor evolving medical and prescription drug trends, applying responsive case management strategies.
• Apply deep knowledge of complex claim practices and legal precedents to resolve unique or precedent-setting matters.
• Partner with peers and leadership to establish, refine, and institutionalize claims policies and best practices.
• Manage communications with policyholders, administrators, top-tier brokers, sales representatives, vendors, and internal partners.
• Coach and mentor less experienced team members, including developing learning modules and supporting technical development.
• Train new hires on accurate claim reimbursement practices and client service expectations.
• Manage monthly accommodation advance payment claims and assigned claim blocks while maintaining turnaround times and service quality.
• Stay current on industry practices and contribute to evolving claims management techniques.
• Serve as a departmental leader and subject matter expert, including participating in field visits and settlement discussions.

Skills

Complex claims

Communication

Negotiation

Leadership

Decision making

Job description

Sun Life U.S. embraces a hybrid work model balancing in-office collaboration with virtual work across contiguous states plus AK.

The Senior Claim Analyst leads complex claim evaluation, investigation, negotiation, and settlement to ensure accurate payments while balancing policy owners and company interests. You will mentor analysts, support training, and develop claim policies, coordinating across brokers, administrators, and internal partners to drive best practices in a high-stakes