Note: The job is a remote job and is open to candidates in USA. 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 all claims contain the necessary documentation for determination, while managing customer service and financial risk associated with Stop Loss claims.
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
Skills
• Bachelor's degree preferred
• 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 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
• Ability to travel
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
Company Overview
• Sun Life is a leading financial services organization dedicated to helping people achieve lifetime financial security and live healthier lives. It was founded in 1865, and is headquartered in Toronto, Ontario, CAN, with a workforce of 10001+ employees. Its website is https://www.sunlife.com.vn/vn/.