Claims Investigation Services Senior Consultant

We need to output HTML fragment with sections: headings

for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We need to parse the job posting. First, there is a description about Sun Life U.S. (company overview). That could be "About the role"? Actually "About the role" is typical heading for overview of role. The posting includes a paragraph about Sun Life U.S. and its purpose, values, etc. That's more about company. Could be "About the role" or maybe we treat as "About the role". The instruction: do NOT repeat the job title as a heading. The job title is "Senior Consultant, Claims Investigation Services (CIS)". So we should not put that as heading. We need sections: maybe "About the role" (company overview and role purpose), "Responsibilities", "Qualifications", "Skills" (Preferred Skills?), "Benefits", "Pay". Also maybe "Schedule" not present, so omit. We must preserve all substantive information, not invent or summarize away detail. Use

• for any list of duties/requirements/benefits, and

  for prose. We need to extract lists. Let's parse sections: - Intro paragraph about Sun Life U.S. (company overview). That's prose. - "Job Description: The Senior Consultant, Claims Investigation Services (CIS) is responsible for department quality control and audit responsibilities in addition to leading complex investigations involving suspected fraud, abuse, misrepresentation, provider misconduct, and other irregular claim activity across Sun Life U.S. Supplemental Health products, including Accident, Critical Illness, Cancer and Hospital Indemnity." That's prose describing role. - Then "Preferred Skills" heading (in original). Under that bullet list: Serve as the subject matter expert for Supplemental Health fraud investigations. Train claims professionals to identify fraud indicators and escalation triggers. Provide consultation and guidance on suspicious claims. Develop investigation playbooks, reference materials, and best practices. Foster awareness of fraud risks across Claims Operations. These are bullet points. - Then "Qualifications" heading (original). Under that bullet list: Bachelor's degree or equivalent experience. Strong analytical and problem-solving skills. Experience reviewing medical records and claim documentation. Ability to conduct complex investigations independently. Strong written and verbal communication skills. Experience presenting findings to senior leadership. - Then "Responsibilities" heading (original). Under that multiple sub-sections with bullet lists. We need to capture all responsibilities bullet points. Let's extract: 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. - Document investigative findings, recommendations, and outcomes. Quality Audit & Claims Procedure Oversight - Conduct quality audits of staff-processed claims to ensure consistent and accurate application of claim department guidelines, procedures, policy provisions, and benefit adjudication standards. - Identify quality trends, error patterns, process gaps, and coaching opportunities that may impact claim accuracy, timeliness, member experience, or operational consistency. - Provide audit findings, feedback, and recommendations to Claims Operations leaders to support staff development, procedural alignment, and continuous improvement. - Maintain audit documentation and reporting to support quality control oversight, management review, and adherence to internal claim handling requirements. Fraud Detection & Analytics - Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies. - Identify high-risk claims through: - Claims frequency analysis - Repeat provider patterns - Repeat member behavior - Injury and diagnosis trends - Geographic anomalies - Payment concentration analysis - Prioritize investigation inventory using risk-scoring methodologies. - Quantify financial exposure and recoverable amounts. - Identify emerging fraud schemes and recommend mitigation strategies. Medical Record & Evidence Review - Coordinate medical record procurement and evidence gathering activities. - Validate submitted documentation against provider records. - Evaluate claim eligibility, diagnosis validity, treatment patterns, and supporting evidence. - Identify inconsistencies between claim submissions and medical records. - Work with internal clinical resources as necessary to assess medical appropriateness and validity. Regulatory, Legal & Compliance Support - Partner with Legal, Compliance, Risk Management, and SIU to ensure investigations comply with applicable laws and regulations. - Prepare investigation summaries and supporting materials for internal and external reviews. - Support regulatory inquiries, audits, legal proceedings, and fraud reporting requirements. - Maintain investigation documentation consistent with company protocols and legal requirements. Fraud Prevention & Program Development - Develop proactive fraud prevention strategies for Supplemental Health. - Identify process vulnerabilities that may enable fraudulent activity. - Recommend policy, workflow, automation, and control enhancements. - Partner with Product, Operations, and Technology leaders on fraud mitigation initiatives. - Support enhancement of fraud monitoring tools and investigative capabilities. Training & Expertise - Serve as the subject matter expert for Supplemental Health fraud investigations. - Train claims professionals to identify fraud indicators and escalation triggers. - Provide consultation and guidance on suspicious claims. - Develop investigation playbooks, reference materials, and best practices. - Foster awareness of fraud risks across Claims Operations. Note that Training & Expertise duplicates Preferred Skills list (identical). We'll keep both? The instruction: preserve ALL substantive information; do not invent or summarize away detail. Duplicated lines: we should remove duplicated lines? It says "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." So duplicated lines should be removed. The Training & Expertise list is duplicate of Preferred Skills. So we should remove one occurrence. Which one to keep? Probably keep the Preferred Skills section and drop the duplicate Training & Expertise. Or we could keep both but that would be duplicated lines. Better to remove duplicate. Thus we will have Preferred Skills (or Skills) section with those bullet points. Now after responsibilities, there is "Salary Range: $72,500 - $108,800" and some prose about pay transparency etc. That's Pay section. Then benefits: "At our company, we are committed to pay transparency and equity..." Actually that's still pay. Then later: "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." That's benefits description. Also earlier: "Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities." That's boilerplate maybe but not duplicated lines; it's generic but maybe we keep as part of About the role? Might be considered boilerplate but not specifically listed as removal categories. However it's generic marketing fluff; but we should preserve substantive information. It's not duplicated lines; it's not EEO etc. Might keep. But we should remove application instructions: "Not ready to apply yet but want to stay in touch? Join our talent community..." etc. Also "We will make reasonable accommodations..." etc. Those are application instructions/legal. Should remove. Also "Job Category: Claims - Life & Disability Posting End Date: 30/10/2026" is metadata; we should fold minor metadata into a short

  or drop it. Probably drop. Thus final HTML: sections: -

  About the role

  with paragraphs: company overview and role description. -

  Responsibilities

  with
  • for each bullet. Should we group subheadings? The instruction: use

    for section headings only. Not for subheadings. So we can just list all responsibilities as a flat list? But we could keep subheadings as plain text inside

    ? Not allowed? The instruction: Use

    for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). Use

    • for any list of duties/requirements/benefits, and

      for prose. It doesn't forbid other headings like

      but says use

      for section headings. Probably we should not add other headings; we can embed subheadings as

      ...? but that adds markup not specified. Safer to just list all responsibilities as a flat list, preserving the content. However we might lose grouping but still preserve all bullet points. That's acceptable. Thus we will output a

      with all responsibility bullet points. -

      Qualifications

      with
      • . -

        Skills

        (Preferred Skills) with
        • . -

          Pay

          with

          containing salary range and prose about pay transparency etc. -

          Benefits

          with

          containing benefits description. We need to ensure we don't include any boilerplate like EEO etc. We'll exclude those paragraphs. Let's craft the About the role prose: combine the initial company overview paragraph and the Job Description sentence. Paragraph 1: "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." Paragraph 2 (Job Description): "The Senior Consultant, Claims Investigation Services (CIS) is responsible for department quality control and audit responsibilities in addition to leading complex investigations involving suspected fraud, abuse, misrepresentation, provider misconduct, and other irregular claim activity across Sun Life U.S. Supplemental Health products, including Accident, Critical Illness, Cancer and Hospital Indemnity." We could combine into one

          or two

          . Use

          for prose. Now Responsibilities list: compile all bullet points from the responsibilities sections (excluding duplicate Training & Expertise). Let's list them: 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. - Document investigative findings, recommendations, and outcomes. Quality Audit & Claims Procedure Oversight - Conduct quality audits of staff-processed claims to ensure consistent and accurate application of claim department guidelines, procedures, policy provisions, and benefit adjudication standards. - Identify quality trends