Hybrid Stop-Loss Health Claims Analyst

Sun Life; Hartford (CT); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Comprehensive benefits

401(k) match

Stock purchase options

Paid time off

Job summary

Sun Life U.S. is seeking a Stop Loss Claims professional to review and adjudicate claims, interpret plan documents, and manage reimbursement decisions. This hybrid role requires applying contractual provisions, coordinating with clinical resources, and ensuring documentation supports determinations.

You will work across claims, legal and medical resources to drive cost containment and compliance. Ideal candidates have 3–5 years of first dollar medical or stop loss claim experience, strong

Qualifications

• 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.
• Negotiation, persuasion, and solutions-based underwriting.
• Ability to work in a fast-paced environment; manage multiple priorities with professionalism.
• Overall knowledge of the 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 the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the Sun Life contract) especially with regard to eligibility and exclusions
• Maintain claim block and meet departmental production and quality metrics
• Awareness of industry claim practices
• Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records
• Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.
• Understand where, when and how professional resources both internal and external, e.g. medical, investigative and legal can add value to the process
• Establish cooperative and productive relationships with professional resources

Skills

Stop Loss Claims

Communication skills

Team collaboration

MS Office

Negotiation skills

Fast-paced environment

Healthcare knowledge

Attention to detail

Job description

Sun Life U.S. is seeking a Stop Loss Claims professional to review and adjudicate claims, interpret plan documents, and manage reimbursement decisions. This hybrid role requires applying contractual provisions, coordinating with clinical resources, and ensuring documentation supports determinations.

You will work across claims, legal and medical resources to drive cost containment and compliance. Ideal candidates have 3–5 years of first dollar medical or stop loss claim experience, strong