Senior Consultant, Supplemental Health

ISHE; Milwaukee (WI); Hybrid; USD 71,000 - 107,000; Full time

Benefits offered by this job

Vacation & sick time

Family leave

Medical coverage

Life and AD&D insurance

Disability programs

Sabbatical program

401(k) match

Stock purchase plan

Job summary

Sun Life U.S. is seeking a highly organized Senior Consultant, Supplemental Health Claims to process and adjudicate supplemental health insurance claims in line with company policies and regulatory guidelines.

You will lead the team to ensure accurate payments and exceptional customer service to policyholders, while mentoring other Claims Consultants and staying current on regulations and best practices.

Qualifications

• 5+ years of experience in supplemental health insurance claims processing or medical billing.
• Strong knowledge of medical terminology, coding systems (ICD-10, CPT), and claim adjudication processes.
• Familiarity with healthcare regulations including HIPAA and state insurance laws.
• Excellent analytical, organizational and communication skills.

Responsibilities

• Review and adjudicate supplemental health insurance claims for eligibility and accuracy.
• Verify policy information, coverage details, and endorsements.
• Adjudicate claims following established guidelines and company policies.
• Ensure accuracy of medical coding, diagnoses, and procedure documentation.
• Request additional information from policyholders or providers as needed.
• Collaborate with the claims team to resolve complex or disputed claims.
• Maintain precise records of all claim activities and communicate decisions to stakeholders.
• Stay current on industry trends, regulatory changes, and best practices in claims processing.
• Provide mentorship and feedback to other Claims Consultants.

Skills

Supplemental health claims processing

Medical billing

Medical terminology

ICD-10/CPT coding

Tools

Claims management software

Job description

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

Job Description:

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Internal candidates are not required to relocate near an office.

The opportunity:

We are seeking a highly organized and detail-oriented Senior Consultant, Supplemental Health Claims. In this role you will be responsible for processing and adjudicating supplemental health insurance claims in accordance with company policies and regulatory guidelines. Your primary objective will be to ensure accurate and timely claim payments, while providing exceptional customer service to policyholders. In addition, you will serve as a leader and go to resource for the team to ensure accuracy and the highest level of service for Clients.

How you will contribute:

• Review and evaluate supplemental health insurance claims for eligibility, completeness, and accuracy.
• Verify policy information, coverage details, and any applicable endorsements or riders.
• Adjudicate claims using established guidelines and company policies.
• Determine the accuracy of medical coding, diagnostic information, and procedure documentation.
• Request any necessary additional information or documentation from policyholders or healthcare providers.
• Collaborate with the claims team to investigate and resolve any complex or disputed claims.
• Ensure that claims are processed and paid in compliance with industry regulations and internal procedures.
• Update claim status and maintain detailed and accurate records of all claim activities.
• Communicate claim decisions, payment details, and any additional requirements to policyholders and healthcare providers.
• Respond to inquiries and provide exceptional customer service to resolve any claim-related issues or concerns.
• Stay updated on industry trends, regulatory changes, and best practices in supplemental health insurance claims processing.
• Perform quality assurance reviews and mentor other Claims Consultants by providing feedback and identifying development opportunities with staff and management.
• Evaluate current processes for efficiency and effectiveness
• Provide manager support by assisting with decision making and problem-solving

What you will bring with you:

• Ability to work with a diverse range of people.
• 5+ years of experience in supplemental health insurance claims processing or medical billing.
• Strong knowledge of medical terminology, coding systems (e.g., ICD-10, CPT), and claim adjudication processes.
• Familiarity with healthcare industry regulations, including HIPAA and state insurance laws.
• Excellent analytical skills and attention to detail to accurately review and evaluate claim information.
• Proficient in using claims management software and other computer applications.
• Exceptional organizational and time management skills to prioritize workload and meet deadlines.
• Excellent written and verbal communication skills to effectively interact with policyholders, providers, and internal stakeholders.
• Ability to work independently and as part of a team, demonstrating flexibility and adaptability in a fast-paced environment.
• Strong problem-solving skills, with the ability to resolve claim-related issues effectively and efficiently.
• Commitment to delivering outstanding customer service and maintaining high levels of professionalism.
• Ability to attain and maintain appropriate TPA licenses in accordance with the Claims Licensing Policy

Salary:

$71,100-$106,700

At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We're proud to be recognized in our communities as a top employer. Proudly Great Place to Work® Certified in Canada and the U.S., we've also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.

We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [e-mail] to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.