Stop Loss & Health Claim Analyst

We need to output HTML fragment with sections: About the role? The posting includes description. We need headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections if posting has real specific content. We need to extract content. First, we have introductory paragraph about Sun Life: that's about company, maybe "About the role"? Actually "About the role" could be description of role. The posting includes "Job Description: Sun Life embraces a hybrid work model..." then "The Opportunity: ..." then "How you will contribute:" then bullet list (actually sentences). Then "What you will bring with you:" then bullet list. Then Salary info. Then benefits description later. We need to avoid boilerplate like EEO, accommodation, etc. Remove cookie/navigation/legal/EEO etc. Also remove "Job Category", "Posting End Date". Also remove "Visit our website" etc if it's generic. We need to preserve all substantive info. Let's parse: Company description: "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." That's generic company overview; could be placed under "About the role"? Actually "About the role" is about the job, not company. But we could treat that as "About the role" maybe? However the instruction: "use

for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." So we can decide which sections to include based on content. We have: - Hybrid work model: "Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK." That's about work arrangement; could be under "About the role" or maybe "Schedule"? Actually schedule is about work hours; hybrid model is about location. Could be under "About the role". - The Opportunity: description of responsibilities: reviewing claims, interpreting contracts, dispersing reimbursement, ensuring documentation, customer service, financial risk, applying provisions, plan specs, case management resources, claims practices, developing plan of action, cost containment initiatives. - How you will contribute: bullet list of specific tasks: Determine eligibility, apply contractual provisions, maintain claim block and meet metrics, awareness of industry claim practices, prepare written rationale, knowledge of legal risk and regulatory guidelines, understand where professional resources can add value, establish cooperative relationships. - What you will bring with you: qualifications: 3-5 years experience processing first dollar medical claims or stop loss claim processing, ability to work in team, strong written/verbal communication, knowledge of Stop Loss Claims preferred, demonstrated success in negotiation, persuasion, solutions-based underwriting, ability to work fast-paced, flexibility, overall knowledge of health care industry, proficiency using MS Office. - Salary: Salary Range: $54,100 - $81,200. Also mention discretionary annual incentive award. - Benefits: later paragraph: "We are committed to fostering an inclusive environment..." then "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." We need to extract benefits specifics: 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, flexible inclusive collaborative work environment, recognition. We should not include fluff like "We are committed to fostering an inclusive environment..." maybe that's okay but it's generic. We'll keep substantive benefits. Schedule: Not explicitly mentioned besides hybrid work model. Could be under Schedule? The posting does not give specific hours. Hybrid model is about location not schedule. So maybe we omit Schedule section because no specific schedule info. Pay: we have salary range and discretionary annual incentive award. That's specific. Now we need sections: About the role (maybe includes company overview and hybrid model?), Responsibilities (from The Opportunity and How you will contribute?), Requirements (maybe experience?), Qualifications (education? not given), Skills (communication, teamwork, MS Office, etc.), Benefits, Pay. We must not repeat job title as heading. Not include Job ID etc. We need to preserve all substantive info; do not invent or summarize away detail. So we need to keep details like "reviewing claims, interpreting and comparing contracts, dispersing reimbursement, ensuring that all claims contain the required documentation to support the Stop Loss claim determination." etc. We need to format lists using

• for any list of duties/requirements/benefits. For prose, use

  . We need to decide what goes into each section. Let's draft:

  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. Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK.

  That seems okay. Now Responsibilities: combine The Opportunity and How you will contribute. We could list bullet points: - Reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. - Responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims. - 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. - 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. - 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) especially with regard to eligibility and exclusions. - Maintain claim block and meet departmental production and quality metrics. - Maintain awareness of industry claim practices. - Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records. - Maintain knowledge of legal risk and regulatory/statutory guidelines (HIPAA, 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. - Establish cooperative and productive relationships with professional resources. We need to ensure we don't duplicate. Some overlap; but we should preserve all info. Might be okay. Now Requirements: maybe "A minimum of three to five years’ experience processing first dollar medical claims or stop loss claim processing". Also maybe "Demonstrated ability to work as part of a cohesive team". But that's more skill. We'll separate. Qualifications: maybe not much besides experience; but we could treat experience as qualification. However we have separate sections: Requirements, Qualifications, Skills. The instruction says prefer a few substantive sections over many thin ones. So we might combine Requirements and Qualifications into one? But we need to follow headings only if content exists. We could have: - Requirements: experience. - Qualifications: maybe none specific besides experience; but we could skip Qualifications if no distinct content. - Skills: communication, teamwork, negotiation, persuasion, solutions-based underwriting, fast-paced environment, flexibility, health care industry knowledge, MS Office proficiency. But we need to avoid thin sections. Perhaps we combine Requirements and Qualifications into one section called "Requirements & Qualifications". But the instruction says use those exact headings examples; but we can decide to include only those with real content. If we think Qualifications has no distinct content beyond requirements, we could omit it. Let's see: The posting includes "What you will bring with you:" which includes experience, teamwork, communication skills, knowledge of Stop Loss Claims preferred, negotiation/persuasion/solutions-based underwriting, ability to work fast-paced, flexibility, overall knowledge of health care industry, proficiency using MS Office. Thus we can treat that as Skills (and maybe Requirements). Experience is a requirement. So we can have:

  Requirements

  • A minimum of three to five years’ experience processing first dollar medical claims or stop loss claim processing

  Skills

  • 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
  Now Benefits: we need to list specifics. Benefits paragraph: "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 could also include recognition but that's fluff. We'll keep substantive benefits. Thus:

  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 sabbat