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Sun Life · 2 hours ago

Stop Loss & Health Claim Analyst

Portland, ME

Full-time

Onsite

Mid Level

$55K/yr - $82K/yr

3+ years exp

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. The Stop Loss & Health Claim Analyst is responsible for reviewing claims, interpreting contracts, and ensuring proper documentation for Stop Loss claims while managing customer service and financial risks associated with these claims.

FinanceFinancial ServicesInsurance

Culture & Values

Responsibilities

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

The ability to 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

An 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

Knowledge of legal risk and regulatory/statutory guidelines HIPPA, 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

Qualification

Stop Loss ClaimsClaims ProcessingContractual ProvisionsHealth Care IndustryMicrosoft OfficeWritten CommunicationVerbal CommunicationTeam CollaborationNegotiation SkillsProblem Solving