Senior Health Claims Analyst & Stop-Loss Expert

Sunlife; Baltimore (MD); Hybrid; USD 71,000 - 106,000; Full time

Benefits offered by this job

Vacation and sick time

Parental and adoption leave

Medical coverage

Life and AD&D insurance

401(k) employer match

Stock purchase options

Partially paid sabbatical

Job summary

Sun Life U.S. is seeking a Senior Claim Analyst in Health and Risk Solutions to lead evaluation, negotiation, and settlement of complex medical, Stop Loss, and reinsurance claims. You will mentor analysts and support training while ensuring accurate, efficient claim payments.

The role requires deep knowledge of complex claims, litigation precedents, and healthcare legislation, with strong communication and leadership skills. Sun Life offers a hybrid work model and comprehensive benefits.

Qualifications

• 7+ years of experience handling complex medical claims including Medical Stop Loss and health reinsurance.
• Deep knowledge of complex claim practices, legal precedents, claims accounting, and healthcare legislation.
• Strong judgment, initiative and consultative decision-making with influencing skills.
• Industry involvement through peer presentations and professional forums.
• Established industry network for exchanging ideas and trends.

Responsibilities

• Manage overall claim risk, including pay/deny decisions, applying contract language and action plans for complex Stop Loss claims.
• Coordinate complex claims across multiple parties, ensuring timely sequencing of actions.
• Identify and monitor evolving medical and prescription drug trends; apply case management strategies.
• Apply knowledge of claim practices and precedents to resolve complex matters.
• Partner with peers to refine and institutionalize claims policies and best practices.
• Manage communications with policyholders, brokers, sales reps, vendors and internal partners.
• Coach and mentor junior team members; develop learning modules and technical development.
• Train new hires on accurate claim reimbursement and client service expectations.
• Manage monthly accommodation advance payment claims and assigned claim blocks; maintain turnaround times.
• Stay current on industry practices and contribute to evolving claims management techniques.
• Serve as departmental leader, participating in field visits and settlement discussions.

Skills

Complex medical claims

Medical Stop Loss

Health reinsurance

Excess medical

Claims practices

Legal precedents

Claims accounting

Communication

Negotiation

Written communication

Problem solving

Industry involvement

Job description

Sun Life U.S. is seeking a Senior Claim Analyst in Health and Risk Solutions to lead evaluation, negotiation, and settlement of complex medical, Stop Loss, and reinsurance claims. You will mentor analysts and support training while ensuring accurate, efficient claim payments.

The role requires deep knowledge of complex claims, litigation precedents, and healthcare legislation, with strong communication and leadership skills. Sun Life offers a hybrid work model and comprehensive benefits.