Stop Loss & Health Claim Analyst

National African-American Insurance Association (NAAIA) WorkFromHome

Stellenbeschreibung:

Sun Life‌U.S. is one of the largest providers of employee and government benefits, helping approximately 50‌million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life‌U.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.

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

Job Description

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.

Stakeholder and Process Responsibilities

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
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
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 HIPAA, 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

Bachelor's degree preferred
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
Ability to travel

Salary Range: $54,900 - $82,400

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.

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 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.

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 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.