Stop Loss & Health Claim Analyst

sunlife; United States; Hybrid; USD 54,000 - 81,000; Full time

Job summary

Sun Life U.S. is a leading provider of employee and government benefits with a hybrid work model across the contiguous states and Alaska. This role focuses on reviewing claims, interpreting contracts, and determining reimbursements while ensuring documentation supports Stop Loss determinations.

The candidate will manage claim blocks, apply contractual provisions, and collaborate with clinical resources to optimize outcomes and cost containment.

Qualifications

• Three to five years of experience processing first-dollar medical claims or stop-loss claims.
• Strong written and verbal communication skills.
• Proficiency using the Microsoft Office suite.

Responsibilities

• Determine eligibility of assigned claims by applying contractual provisions to medical facts and claim specs.
• Apply provisions from underlying policyholder plan and Sun Life contract regarding eligibility and exclusions.
• Maintain claim block and meet departmental production and quality metrics.
• Maintain awareness of industry claim practices.
• Prepare written rationale of claim decisions based on provisions, plan specs, and medical records.
• Know HIPAA, privacy, and ACA regulatory guidelines.
• Coordinate internal and external resources to add value to the process.
• Establish cooperative relationships with professional resources.

Skills

Claims processing

Communication

Team player

Stop Loss knowledge

MS Office

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

This position is responsible for reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. They are responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional case management resources; and claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim. The incumbent is accountable for developing, coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources.

How you will contribute

• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
• The ability to apply the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the Sun Life contract) especially with regard to eligibility and exclusions
• Maintain claim block and meet departmental production and quality metrics
• An awareness of industry claim practices
• Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records
• Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.
• Understand where, when and how professional resources both internal and external, e.g. medical, investigative and legal can add value to the process
• Establish cooperative and productive relationships with professional resources

What you will bring with you

• A minimum of three to five years' experience processing first dollar medical claims or stop loss claim processing
• Demonstrated ability to work as part of a cohesive team
• Strong written and verbal communication skills
• Knowledge of Stop Loss Claims and Stop Loss industry preferred
• Demonstrated success in negotiation, persuasion, and solutions-based underwriting
• Ability to work in a fast-paced environment; flexibility to handle multiple priorities while maintaining a high level of professionalism
• Overall knowledge of health care industry
• Proficiency using the Microsoft Office suite of products

Salary

Salary Range: $54,100 - $81,200

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.

Diversity & Inclusion

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