Stop Loss & Health Claim Analyst

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. The company has more than 6,400 employees and associates in partner dental practices and operates nationwide. Sun Life embraces a hybrid work model that balances in‑office collaboration with the flexibility of virtual work in the contiguous states plus AK.

Responsibilities

• Review claims
• Interpret and compare contracts
• Disburse reimbursement
• Ensure claims contain required documentation to support Stop Loss claim determination
• Provide customer service
• Manage the financial risk associated with an assigned block of Stop Loss claims
• Apply 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
• Develop, coordinate and implement a plan of action for each accepted claim to ensure effective management and implementation of all cost containment initiatives with clinical resources
• Determine, on a timely basis, the eligibility