Stop Loss Claims Resolution Consultant
Job Description
The opportunity: The Claims Resolution Consultant serves as a subject matter expert in Stop Loss medical claims and is the primary point of contact for complex claim inquiries, escalations, and resolution support. This role combines deep technical expertise as a Stop Loss Health Claims Analyst with responsibility for managing end-to-end inquiry resolution, including research, claim determination support, documentation review, and clear customer communication.
This role requires strong judgment, advanced understanding of stop loss products, and the ability to explain complex claim matters clearly to TPAs, brokers, employers, sales partners, and internal stakeholders.
How You Will Contribute
Serve as an expert resource for Stop Loss medical claims, including large-loss and complex claim scenarios, reimbursement determinations, exclusions, and eligibility issues.
Research and resolve advanced claim inquiries by analyzing claim history, medical documentation, reimbursement data, plan documents, and Sun Life stop-loss contract provisions.
Interpret and apply contractual language consistently, identifying when issues require escalation, exception handling, or clinical, legal, or investigative review.
Provide consultative guidance to requestors on claim status, required documentation, anticipated timelines, and next steps.
Own inquiries from intake through closure, ensuring accountability, tracking, and follow-up.
Acknowledge inquiries promptly, provide clear expectations for updates and resolution timing, and proactively communicate if timelines change.
Deliver clear, concise, and customer-appropriate written communication (primarily email) that summarizes findings, decisions, and supporting rationale.
Identify inquiries that require adjudication or reimbursement review and route to appropriate Claims Analysts or Senior Analysts with complete and organized handoffs.
Partner collaboratively with internal teams including Claims, Overpayments, Client Management, Sales, Clinical Resources, and Legal to support accurate and timely outcomes.
Participate in client implementation, onboarding, or issue-resolution calls as needed, explaining stop loss claim processes and outcomes clearly.
Document research, decisions, communications, and handoffs thoroughly in the system of record.
Ensure all claim handling complies with privacy, security, and regulatory requirements (HIPAA, etc.).
Apply sound claim practices and professional judgment to identify trends, risks, or recurring issues impacting customer experience or operational efficiency.
Act as a go-to resource for peers and partners by sharing expertise on stop loss claim handling, documentation standards, and common contract provisions.
Identify opportunities for process improvements, enhanced job aids, or clearer communication templates based on inquiry volume and trends.
Contribute to a strong service culture through collaboration, follow-through, and a solutions-oriented mindset.
What You Will Bring
Expert-level knowledge of Stop Loss medical claims, including eligibility determination, reimbursement workflows, documentation requirements, and contract interpretation.
Experience reviewing and supporting complex or large loss stop loss claims end-to-end.
Strong ability to interpret and explain plan documents and contract provisions.
Demonstrated experience navigating claims systems, reporting, and internal knowledge resources.
Excellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.
Strong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.
Proven judgment in identifying when issues require escalation and how to route them effectively.
3–5+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.
Experience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.
Familiarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.
Experience contributing to job aids, playbooks, or process improvement initiatives.
Advanced analytical and problem-solving skills.
Strong customer-focused service orientation.
Professional judgment and discretion with sensitive information.
Clear, confident communication and documentation.
Collaboration across operational and clinical teams.
Accountability for outcomes and follow-through.
Continuous improvement mindset.
Salary Range
$54,100 - $81,200
At our company, 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.
About the Role
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.
Requirements
Expert-level knowledge of Stop Loss medical claims, including eligibility determination, reimbursement workflows, documentation requirements, and contract interpretation.
Experience reviewing and supporting complex or large loss stop loss claims end-to-end.
Strong ability to interpret and explain plan documents and contract provisions.
Demonstrated experience navigating claims systems, reporting, and internal knowledge resources.
Excellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.
Strong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.
Proven judgment in identifying when issues require escalation and how to route them effectively.
3–5+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.
Experience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.
Familiarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.
Experience contributing to job aids, playbooks, or process improvement initiatives.
Advanced analytical and problem-solving skills.
Strong customer-focused service orientation.
Professional judgment and discretion with sensitive information.
Clear, confident communication and documentation.
Collaboration across operational and clinical teams.
Accountability for outcomes and follow-through.
Continuous improvement mindset.
Qualifications
Expert-level knowledge of Stop Loss medical claims, including eligibility determination, reimbursement workflows, documentation requirements, and contract interpretation.
Experience reviewing and supporting complex or large loss stop-loss claims end-to-end.
Strong ability to interpret and explain plan documents and contract provisions.
Demonstrated experience navigating claims systems, reporting, and internal knowledge resources.
Excellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.
Strong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.
Proven judgment in identifying when issues require escalation and how to route them effectively.
3–5+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.
Experience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.
Familiarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.
Experience contributing to job aids, playbooks, or process improvement initiatives.
Advanced analytical and problem-solving skills.
Strong customer-focused service orientation.
Professional judgment and discretion with sensitive information.
Clear, confident communication and documentation.
Collaboration across operational and clinical teams.
Accountability for outcomes and follow-through.
Continuous improvement mindset.
Skills
Expert-level knowledge of Stop Loss medical claims, including eligibility determination, reimbursement workflows, documentation requirements, and contract interpretation.
Experience reviewing and supporting complex or large loss stop loss claims end-to-end.
Strong ability to interpret and explain plan documents and contract provisions.
Demonstrated experience navigating claims systems, reporting, and internal knowledge resources.
Excellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.
Strong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.
Proven judgment in identifying when issues require escalation and how to route them effectively.
3–5+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.
Experience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.
Familiarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.
Experience contributing to job aids, playbooks, or process improvement initiatives.
Advanced analytical and problem-solving skills.
Strong customer-focused service orientation.
Professional judgment and discretion with sensitive information.
Clear, confident communication and documentation.
Collaboration across operational and clinical teams.
Accountability for outcomes and follow-through.
Continuous improvement mindset.
Benefits
Comprehensive benefits package 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.
Opportunities for career growth and development, including a 401(k) employer match, stock purchase options, and an employer-funded retirement account.
A supportive and inclusive work environment that fosters collaboration, innovation, and continuous improvement.
Recognition as a top employer in the communities we serve, including being recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.
Commitment to diversity, equity, and inclusion, with a focus on creating a workplace where everyone feels valued and empowered to thrive.
Pay
$54,100 - $81,200
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.
Schedule
N/A