Sr. Claims Analyst, Health and Risk Solutions

RiseMe; Maryland; Hybrid; USD 68,000 - 102,000; Full time

Job summary

Sun Life U.S. is seeking a Senior Claim Analyst for the Health and Risk Solutions unit. The role leads evaluation, investigation, negotiation, and settlement of complex claims, supporting training and mentoring for analysts and overpayment specialists.

You will manage claim risk, coordinate activities across parties, and apply deep knowledge of contract language, legal precedents, and healthcare legislation to ensure accurate payments and compliant processes.

Qualifications

• 7+ years of experience handling complex medical stop loss or complex medical claims.
• Deep knowledge of complex claim practices, legal precedents and healthcare legislation.
• Strong judgment, initiative and consultative decision-making with influence.
• Recognized SME with industry involvement and network.
• Excellent communication, negotiation and influencing skills.
• Ability to draft clear, compliant written correspondence.
• Creative, resourceful problem-solving for complex matters.
• Experience in leading training and learning modules.

Responsibilities

• Manage overall claim risk and pay/deny decisions using contract language and action plans for complex Stop Loss claims.
• Coordinate complex claims activity across multiple parties ensuring timely completion.
• Identify evolving medical and prescription drug trends and apply responsive case management.
• Apply knowledge of complex claims and legal precedents to resolve unique matters.
• Partner with leadership to establish and refine claims policies and best practices.
• Communicate with policyholders, administrators, brokers, sales, vendors and internal partners.
• Coach and mentor junior team members and develop training modules.

Skills

Complex claims management

Medical Stop Loss knowledge

Stakeholder management

Mentoring and coaching

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.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

Job Description

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK.

The opportunity

The Health and Risk Solutions Senior Claim Analyst serves as the highest level of technical expertise within the claims unit, leading the evaluation, investigation, negotiation, and settlement of complex claims and risk matters.

In this role, you will help ensure legitimate claims and benefits are paid accurately and efficiently while balancing the interests of policy owners and the company. You will also play a key role in managing internal and external relationships, supporting new hire training, and coaching and mentoring Health and Risk Solutions Claim Analysts and Overpayment Specialists.

How you will contribute

• Manage overall claim risk, including pay/deny decisions, by applying contract language and developing action plans for complex Stop Loss claims.
• Coordinate complex claims activity across multiple parties, ensuring actions are appropriately sequenced and completed on time.
• Identify and monitor evolving medical and prescription drug trends, applying responsive case management strategies.
• Apply deep knowledge of complex claim practices and legal precedents to resolve unique or precedent-setting matters.
• Partner with peers and leadership to establish, refine, and institutionalize claims policies and best practices.
• Manage communications with policyholders, administrators, top-tier brokers, sales representatives, vendors, and internal partners.
• Coach and mentor less experienced team members, including developing learning modules and supporting technical development.
• Train new hires on accurate claim reimbursement practices and client service expectations.
• Manage monthly accommodation advance payment claims and assigned claim blocks while maintaining turnaround times and service quality.
• Stay current on industry practices and contribute to evolving claims management techniques.
• Serve as a departmental leader and subject matter expert, including participating in field visits and settlement discussions.

What you will bring with you

• Ability to work with a diverse range of people.
• 7+ years of experience handling complex claims, Medical Stop Loss or complex Medical Claims
• Deep knowledge of complex claim practices, legal precedents, claims accounting, and applicable state and federal healthcare legislation.
• Strong judgment, initiative, and consultative decision-making, with the ability to influence recommendations that may impact company operations.
• Recognized subject matter expertise, including industry involvement through peer presentations, panels, or professional forums.
• Established industry network to exchange ideas, trends, and emerging claim management techniques.
• Excellent communication, negotiation, and influencing skills, including the ability to navigate conflict and align stakeholders.
• Ability to draft clear, compliant written correspondence that meets guidelines and is easily understood by the recipient.
• Creative, resourceful problem-solving skills, including the ability to develop action plans and resolve complex matters using specialized resources or claims management techniques.

Salary

$68,200-$102,300

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.

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 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.

Job Category

Claims - Health & Dental

Posting End Date

09/10/2026