Senior Consultant, Supplemental Health

About the Role

Sun Life U.S. is seeking a highly organized and detail-oriented Senior Consultant, Supplemental Health Claims, to process and adjudicate claims in accordance with company policies and regulatory guidelines. This role ensures accurate and timely claim payments while providing exceptional customer service to policyholders and serves as a leader and resource for the team.

Responsibilities

• Review and evaluate supplemental health insurance claims for eligibility, completeness, and accuracy.
• Verify policy information, coverage details, and any applicable endorsements or riders.
• Adjudicate claims using established guidelines and company policies.
• Determine the accuracy of medical coding, diagnostic information, and procedure documentation.
• Request necessary additional information or documentation from policyholders or healthcare providers.
• Collaborate with the claims team to investigate and resolve complex or disputed claims.
• Ensure claims are processed and paid in compliance with industry regulations and internal procedures.
• Update claim status and maintain detailed records of all claim activities.
• Communicate claim decisions, payment details, and requirements to policyholders and healthcare providers.
• Respond to inquiries and resolve claim-related issues.
• Stay updated on industry trends, regulatory changes, and best practices.
• Perform quality assurance reviews and mentor Claims Consultants.
• Evaluate processes for efficiency and effectiveness.
• Assist managers with decision-making and problem-solving.

Requirements

• 5+ years of experience in supplemental health insurance claims processing or medical billing.
• Strong knowledge of medical terminology, coding systems (e.g., ICD-10, CPT), and claim adjudication processes.
• Familiarity with healthcare industry regulations, including HIPAA and state insurance laws.
• Proficiency in claims management software and computer applications.
• Ability to attain and maintain appropriate TPA licenses.

Qualifications

• Excellent analytical skills and attention to detail.
• Exceptional organizational and time management skills.
• Strong written and verbal communication skills.
• Ability to work independently and as part of a team.
• Strong problem-solving skills.
• Commitment to outstanding customer service and professionalism.

Skills

• Ability to work with a diverse range of people.
• Flexibility and adaptability in a fast-paced environment.

Pay

Salary range: $71,100–$106,700. Actual base salary determined by skills, qualifications, experience, education, and geographic location. Eligible for a discretionary annual incentive award based on individual and business performance.

Benefits

• Generous vacation and sick time.
• Market-leading paid family, parental, and adoption leave.
• Medical coverage.
• Company-paid life and AD&D insurance.
• Disability programs.
• Partially paid sabbatical program.
• 401(k) employer match.
• Stock purchase options.
• Employer-funded retirement account.