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 employs more than 6,400 employees and associates in partner dental practices nationwide and is driven by its Purpose: helping clients achieve lifetime financial security and live healthier lives.

The Opportunity: This position is responsible for reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. The incumbent provides customer service and manages the financial risk associated with an assigned block of Stop Loss claims by applying appropriate contractual provisions, plan specifications, professional case management resources, and claims practices to the medical facts of each claim to decide on reimbursement or denial. They 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.

Responsibilities

• Determine, on a timely basis, the eligibility of assigned claims 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 and the Sun Life contract), especially regarding eligibility and exclusions.
• Maintain claim block and meet departmental production and quality metrics.
• Maintain awareness of industry claim practices.
• Prepare written rationale of claim decisions based on review of contractual provisions, plan specifications, and analysis of medical records.
• Demonstrate knowledge of legal risk and regulatory/statutory guidelines (HIPAA, privacy, Affordable Care Act, etc.).
• Understand where, when, and how professional resources (internal and external, e.g., medical, investigative, legal) can add value to the process.
• Establish cooperative and productive relationships with professional resources.

Requirements

• A minimum of three to five years’ experience processing first‑dollar medical claims or stop‑loss claim processing.
• Demonstrated ability to work as part of a cohesive team.
• Strong written and verbal communication skills.
• Knowledge of Stop Loss Claims and the 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 the health care industry.
• Proficiency using the Microsoft Office suite of products.

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.
• Flexible, inclusive, and collaborative work environment that supports career growth.
• Recognition as a Great Place to Work® Certified employer in Canada and the U.S., and a “Top 10” employer by the Boston Globe's “Top Places to Work” for two consecutive years.

Pay

The salary range for this role is $54,100 – $81,200. In addition to base salary, the position is eligible for a discretionary annual incentive award based on individual performance and overall business performance.

Schedule

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