Stop Loss & Health Claim Analyst

Sun Life; Wellesley (MA); Hybrid; USD 54,000 - 81,000; Full time

Benefits offered by this job

Comprehensive benefits

Vacation & sick time

Paid family leave

401(k) match

Stock purchase options

Sabbatical program

Flexible work environment

Job summary

Sun Life U.S. is seeking a Stop Loss Claims Specialist to review and adjudicate first-dollar medical and stop loss claims.

You will apply contractual provisions and plan specifications to determine eligibility and reimbursement, while coordinating with clinical resources to contain costs. The ideal candidate has 3–5 years’ experience in stop loss or first-dollar medical claims, excellent written and verbal communication skills, and the ability to manage multiple priorities in a hybrid work

Qualifications

• Minimum 3–5 years' experience processing first dollar medical claims or stop loss claim processing
• Strong written and verbal communication skills
• Knowledge of Stop Loss Claims and Stop Loss industry preferred
• Demonstrated success in negotiation and solutions-based underwriting
• Ability to work in a fast-paced environment with multiple priorities and professionalism

Responsibilities

• Review claims on a timely basis and determine eligibility applying contractual provisions
• Interpret and apply plan specifications and Sun Life contracts for reimbursement decisions
• Maintain claim block and meet departmental production and quality metrics
• Coordinate with internal and external resources (medical, investigative, legal) to add value
• Prepare written rationale of claim decisions based on contracts and medical records

Skills

Stop Loss claims

First-dollar medical claims

Team player

Communication skills

Negotiation

Fast-paced

Regulatory knowledge

Problem solving

Healthcare industry knowledge

Microsoft Office

Tools

Microsoft 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 ofprofessionalism
• 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.

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're proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S., we've also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.

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.

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:

22/10/2026