Hybrid Stop-Loss & Health Claims Analyst

Sun Life; Wellesley (MA); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Comprehensive benefits

Vacation & sick time

Paid family leave

401(k) match

Stock purchase options

Sabbatical program

Flexible work environment

Job summary

Sun Life U.S. is seeking a Stop Loss Claims Specialist to review and adjudicate first-dollar medical and stop loss claims.

You will apply contractual provisions and plan specifications to determine eligibility and reimbursement, while coordinating with clinical resources to contain costs. The ideal candidate has 3–5 years’ experience in stop loss or first-dollar medical claims, excellent written and verbal communication skills, and the ability to manage multiple priorities in a hybrid work

Qualifications

• Minimum 3–5 years' experience processing first dollar medical claims or stop loss claim processing
• Strong written and verbal communication skills
• Knowledge of Stop Loss Claims and Stop Loss industry preferred
• Demonstrated success in negotiation and solutions-based underwriting
• Ability to work in a fast-paced environment with multiple priorities and professionalism

Responsibilities

• Review claims on a timely basis and determine eligibility applying contractual provisions
• Interpret and apply plan specifications and Sun Life contracts for reimbursement decisions
• Maintain claim block and meet departmental production and quality metrics
• Coordinate with internal and external resources (medical, investigative, legal) to add value
• Prepare written rationale of claim decisions based on contracts and medical records

Skills

Stop Loss claims

First-dollar medical claims

Team player

Communication skills

Negotiation

Fast-paced

Regulatory knowledge

Problem solving

Healthcare industry knowledge

Microsoft Office

Tools

Microsoft Office

Job description

Sun Life U.S. is seeking a Stop Loss Claims Specialist to review and adjudicate first-dollar medical and stop loss claims.

You will apply contractual provisions and plan specifications to determine eligibility and reimbursement, while coordinating with clinical resources to contain costs. The ideal candidate has 3–5 years’ experience in stop loss or first-dollar medical claims, excellent written and verbal communication skills, and the ability to manage multiple priorities in a hybrid work