Hybrid Stop-Loss Claims Analyst | Health Benefits

Sun Life; Baltimore (MD); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Vacation & sick time

Family leave

Medical coverage

Life/AD&D insurance

Disability programs

Sabbatical program

401(k) match

Stock purchase options

Job summary

Sun Life U.S. is a major employer in the benefits space, offering a hybrid work model that blends in-office collaboration with virtual work across the contiguous states plus AK.

The role focuses on reviewing claims, applying contractual provisions, and determining reimbursements while managing a Stop Loss claim block and associated costs. You will work to ensure compliance with plan documents and professional resources, with emphasis on accuracy, teamwork, and customer service in a fast-paced

Qualifications

• A minimum of three to five years' experience processing first dollar medical claims or stop loss claim processing.
• Demonstrated ability to work as part of a cohesive team.
• Strong written and verbal communication skills.
• Knowledge of Stop Loss Claims and Stop Loss industry preferred.
• Demonstrated success in negotiation, persuasion, and solutions-based underwriting.
• Ability to work in a fast-paced environment; handling multiple priorities with professionalism.
• Overall knowledge of health care industry.
• Proficiency using the Microsoft Office suite of products.

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 both the underlying policyholder plan and the Sun Life contract regarding eligibility and exclusions.
• Maintain claim block and meet departmental production and quality metrics.
• Maintain awareness of industry claim practices.
• Prepare written rationale of claim decision based on contract provisions, plan specs, and medical records analysis.
• Understand legal risk and regulatory guidelines such as HIPAA and ACA.
• Coordinate internal and external resources to add value to the process.
• Establish cooperative relationships with professional resources.

Skills

Claims processing

Stop Loss

Team collaboration

Communication

Microsoft Office

Tools

Microsoft Office

Job description

Sun Life U.S. is a major employer in the benefits space, offering a hybrid work model that blends in-office collaboration with virtual work across the contiguous states plus AK.

The role focuses on reviewing claims, applying contractual provisions, and determining reimbursements while managing a Stop Loss claim block and associated costs. You will work to ensure compliance with plan documents and professional resources, with emphasis on accuracy, teamwork, and customer service in a fast-paced