Hybrid Stop-Loss Claims Analyst

Sun Life; Portland (ME); Hybrid; USD 54,000 - 81,000; Full time

Job summary

Sun Life U.S. in Portland, ME is seeking a Claims Analyst, Health and Risk Solutions to review claims, interpret contracts, and determine reimbursement for Stop Loss cases.

This hybrid role requires applying plan specifications, maintaining documentation, and coordinating with clinical and legal resources to contain costs while ensuring compliant claim denials or payments.

The position offers a supportive team environment, comprehensive benefits, and opportunities for professional growth.

Qualifications

• 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.

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 contractual provisions from the underlying policyholder plan and the Sun Life contract, especially for eligibility and exclusions.
• Maintain claim block and meet departmental metrics.
• Maintain awareness of industry claim practices.
• Prepare written rationale of claim decision based on review of contractual provisions and plan specifications and the analysis of medical records.
• Knowledge of legal risk and regulatory/statutory guidelines HIPAA, privacy, ACA, etc.
• Understand where professional resources can add value to the process.
• Establish cooperative and productive relationships with professional resources.

Skills

Health care knowledge

Negotiation

Communication

Teamwork

Multi-tasking

Microsoft Office

Travel ability

Education

Bachelor's degree preferred

Tools

Microsoft Office

Job description

Sun Life U.S. in Portland, ME is seeking a Claims Analyst, Health and Risk Solutions to review claims, interpret contracts, and determine reimbursement for Stop Loss cases.

This hybrid role requires applying plan specifications, maintaining documentation, and coordinating with clinical and legal resources to contain costs while ensuring compliant claim denials or payments.

The position offers a supportive team environment, comprehensive benefits, and opportunities for professional growth.