Remote Stop-Loss Claims Specialist

Sun Life; United States; Hybrid; USD 54,100 - 81,200; Full time

Job summary

Sun Life U.S. is seeking a Stop‑Loss Claims Specialist to review and decide on medical claims, applying plan provisions and industry standards. You will deliver customer service, manage claim blocks, and support risk management across the U.S. workforce. The role demands strong analytical and communication skills in a fast-paced environment.

Hybrid work model across the contiguous United States and Alaska offers in-office collaboration with flexible remote work.

Qualifications

• Three to five years of experience in processing first-dollar medical claims or Stop-Loss claim processing.
• Excellent written and verbal communication skills.
• Knowledge of Stop-Loss claims and the industry is preferred.
• Proven negotiation, persuasion, and solutions-based underwriting abilities.
• Capacity to thrive in a fast-paced environment and manage multiple priorities professionally.

Responsibilities

• Determine the eligibility of assigned claims by applying contractual provisions and claim specifications.
• Apply both the underlying plan and Sun Life contract provisions for eligibility and exclusions.
• Maintain claim blocks and meet departmental production and quality metrics.
• Prepare written rationale for claim decisions based on contract review and medical record analysis.
• Assess legal, regulatory, and statutory guidelines (HIPAA, Affordable Care Act, etc.).
• Identify when and how to involve professional resources—medical, investigative, and legal—to add value.
• Establish cooperative relationships with professional resources.

Skills

Teamwork

Communication

MS Office

Negotiation

Underwriting

Job description

Sun Life U.S. is seeking a Stop‑Loss Claims Specialist to review and decide on medical claims, applying plan provisions and industry standards. You will deliver customer service, manage claim blocks, and support risk management across the U.S. workforce. The role demands strong analytical and communication skills in a fast-paced environment.

Hybrid work model across the contiguous United States and Alaska offers in-office collaboration with flexible remote work.