Claims Investigation Services Senior Consultant
About the role
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.
Responsibilities
- Claims Investigations – Lead investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, or organized fraud schemes. Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information, and payment history. Analyze claim activity to identify unusual patterns, trends, or indicators of fraud. Develop and execute investigation plans based on risk, complexity, and financial exposure. Determine appropriate investigative actions and escalation paths