Senior Health & Stop-Loss Claims Lead

Sun Life; Hartford (CT); Hybrid; USD 68,000 - 102,000; Full time

Benefits offered by this job

Generous vacation and sick time

Market-leading paid family leave

Medical coverage

401(k) employer match

Stock purchase options

Employer-funded retirement account

Job summary

Sun Life U.S. is a leading benefits provider with a hybrid work model across contiguous states plus AK. The Health and Risk Solutions Senior Claim Analyst leads evaluation, negotiation and settlement of complex claims, training new hires and mentoring analysts and overpayment specialists.

You will manage claim risk, coordinate activities, monitor trends, and apply legal and regulatory knowledge while guiding internal policy development and external partner relationships.

Qualifications

• 7+ years of experience handling complex claims, Medical Stop Loss or complex Medical Claims.
• Deep knowledge of complex claim practices, legal precedents and healthcare legislation.
• Excellent communication, negotiation and influencing skills.
• Ability to draft clear, compliant written correspondence.
• Established industry network and ongoing professional engagement.

Responsibilities

• Manage overall claim risk and pay/deny decisions using contract language.
• Coordinate complex claims across multiple parties to ensure timely actions.
• Identify evolving medical and prescription drug trends; apply case management.
• Apply advanced knowledge to resolve unique or precedent-setting matters.
• Lead, refine, and institutionalize claims policies and best practices.
• Communicate with policyholders, administrators, brokers, vendors and internal partners.
• Coach and mentor team members; develop learning modules and training.
• Train new hires on reimbursement practices and client service expectations.
• Lead monthly accommodation payments and claim blocks with timely turnaround.

Skills

Complex claims handling

Communication & negotiation

Influencing skills

Drafting clear written correspondence

Mentoring and coaching

Industry networking

Judgement & decision-making

Stop Loss / medical claims knowledge

Job description

Sun Life U.S. is a leading benefits provider with a hybrid work model across contiguous states plus AK. The Health and Risk Solutions Senior Claim Analyst leads evaluation, negotiation and settlement of complex claims, training new hires and mentoring analysts and overpayment specialists.

You will manage claim risk, coordinate activities, monitor trends, and apply legal and regulatory knowledge while guiding internal policy development and external partner relationships.