Stop-Loss Health Claims Specialist

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

Benefits offered by this job

Vacation & sick time

Parental leave

Medical coverage

Life & AD&D insurance

Disability programs

401(k) match

Job summary

Sun Life U.S. is seeking an experienced Stop Loss Claims professional to review and adjudicate claims, applying contract provisions and plan specifications to medical facts.

The role emphasizes accuracy, collaboration, and adherence to regulatory guidelines in a hybrid environment across the contiguous states plus Alaska. The ideal candidate brings 3–5 years in first-dollar or stop-loss claim processing, strong communication, and solid knowledge of the health care landscape.

Qualifications

• 3–5 years’ experience processing first dollar medical claims or stop loss claims.
• 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.
• Negotiation, persuasion, and solutions-based underwriting.
• Ability to handle multiple priorities in a fast-paced environment.
• Overall knowledge of health care industry.
• Proficiency using Microsoft Office suite.

Responsibilities

• 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.
• Apply the appropriate contractual provisions from both the underlying policyholder plan and the Sun Life contract.
• Maintain claim block and meet departmental production and quality metrics.
• Remain aware of industry claim practices.
• Prepare written rationale of claim decisions based on contract provisions, plan specs, and medical records.
• Know regulatory guidelines (HIPAA, privacy, ACA).
• Coordinate internal and external resources to add value to the process.
• Establish cooperative relationships with professional resources.

Skills

Stop Loss Claims

Team player

Communication skills

Microsoft Office

Regulatory knowledge

Job description

Sun Life U.S. is seeking an experienced Stop Loss Claims professional to review and adjudicate claims, applying contract provisions and plan specifications to medical facts.

The role emphasizes accuracy, collaboration, and adherence to regulatory guidelines in a hybrid environment across the contiguous states plus Alaska. The ideal candidate brings 3–5 years in first-dollar or stop-loss claim processing, strong communication, and solid knowledge of the health care landscape.