Stop Loss Claim Analyst - Sun Life Financial - Windsor, CT

CLA03760

This position is available in Wellesley, MA & Windsor, CT

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. They are responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims. This requires 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.

The incumbent is accountable for 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.

Position 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 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


• LI-ML1

Qualifications:

• Bachelor’s degree preferred


• A minimum of five years’ experience processing first dollar medical claims


• Demonstrated ability to work as part of a cohesive team


• Strong written and verbal communication skills


• Significant knowledge of Stop Loss Underwriting and Stop Loss industry preferred, but not required


• 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

No relocation is available

Sun Life Financial is a leading international financial services organization providing a diverse range of protection and wealth accumulation products and services to individuals and corporate customers. Chartered in 1865, Sun Life Financial and its partners today have operations in key markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, and Bermuda.

Sun Life Financial Inc. trades on the Toronto (TSX), New York (NYSE), and Philippine (PSE) stock exchanges under the ticker symbol SLF. For more information, visit

www.sunlife.com/us

.

Join our talented, diverse workforce and launch a rewarding career.

Job

:

Claims – Life & Disability

Primary Location

:

US-CT-Windsor

–

Windsor

175 Addison Road

Windsor

06095

Employee Status

:

Regular

–

Full-time

Unposting Date

:

Ongoing