Claims Analyst, Health and Risk Solutions

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You’ll work with dynamic colleagues – experts in their fields – who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you’ll have new and exciting opportunities to make life brighter for our Clients – who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

Job Description:

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.

The opportunity: The Claims Analyst, Health and Risk Solutions 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 Claims Analyst, Health and Risk Solutions 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) with particular attention to eligibility and exclusions
• Maintain claim block and meet departmental production and quality metrics
• 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
• Build and maintain collaborative and effective partnerships with professional resources

What you will bring with you:

• Ability to work with a diverse range of people
• Bachelor’s degree preferred
• A minimum of 3 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

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Life is brighter when you work at Sun Life

• Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
• Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
• A flexible work environment with a friendly, caring, collaborative and inclusive culture
• Great Place to Work® Certified in Canada and the U.S.
• Named as a “Top 10” employer by the Boston Globe’s “Top Places to Work” two years running

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.

If you are a California resident, the salary range for this position is:

• Southern California region: $58,300-$87,500 annually
• Central California region: $61,500-$92,300 annually
• Northern California region: $65,800-$98,700 annually

If you are a Colorado or Nevada resident, the salary range for this position is $55,700-$83,600 annually

If you are a Connecticut or Maryland resident, the salary range for this position is $58,300-$87,500 annually

If you are Washington or Rhode Island resident, the salary range for this position is $61,500-$92,300 annually

If you are a New York resident, the salary range for this position is $65,800-$98,700 annually