Senior Stop Loss Claims Resolution Consultant

Sustainable World, Inc.; Baltimore, Northern (MD, KY); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Vacation and sick time

401(k) employer match

Life and AD&D insurance

Disability programs

Sabbatical program

Job summary

Sun Life U.S. is actively seeking a Claims Resolution Consultant to serve as a subject-matter expert in Stop Loss medical claims and manage end-to-end inquiry resolution for complex cases.

This role requires deep technical knowledge, strong communication, and collaboration with Claims Analysts, clinical resources, and other internal teams to ensure timely, accurate outcomes while maintaining HIPAA compliance.

Qualifications

• Expert-level knowledge of Stop Loss medical claims, including eligibility determination.
• Experience reviewing and supporting large-loss stop loss claims end-to-end.
• Ability to interpret and explain plan documents and contract provisions.
• Strong written and verbal communication skills, able to explain complex claim matters to non-technical audiences.
• Experience partnering with TPAs, brokers, employers, or sales partners in a consultative role.

Responsibilities

• Serve as an expert resource for Stop Loss medical claims, including large-loss and complex claim scenarios, reimbursement determinations, exclusions, and eligibility issues.
• Research and resolve advanced claim inquiries by analyzing claim history, medical documentation, reimbursement data, plan documents, and Sun Life stop-loss contract provisions.
• Interpret and apply contractual language consistently, identifying when issues require escalation, exception handling, or clinical, legal, or investigative review.
• Provide consultative guidance to requestors on claim status, required documentation, anticipated timelines, and next steps.
• Own inquiries from intake through closure, ensuring accountability, tracking, and follow-up.
• Acknowledge inquiries promptly, provide clear expectations for updates and resolution timing, and proactively communicate if timelines change.
• Deliver clear, concise, and customer-appropriate written communication that summarizes findings, decisions, and supporting rationale.
• Identify inquiries that require adjudication or reimbursement review and route to appropriate Analysts with complete handoffs.
• Partner with internal teams including Claims, Overpayments, Client Management, Sales, Clinical Resources, and Legal to support accurate outcomes.
• Participate in client implementation, onboarding, or issue-resolution calls to explain stop loss processes and outcomes.

Skills

Stop Loss claims

Medical claims processing

Contract interpretation

Written communication

Cross-functional collaboration

HIPAA compliance

Tools

Claims systems

Job description

Sun Life U.S. is actively seeking a Claims Resolution Consultant to serve as a subject-matter expert in Stop Loss medical claims and manage end-to-end inquiry resolution for complex cases.

This role requires deep technical knowledge, strong communication, and collaboration with Claims Analysts, clinical resources, and other internal teams to ensure timely, accurate outcomes while maintaining HIPAA compliance.