Health Plans Claims Processor

S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.
Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

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

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. plan specifications of the underlying plan document; 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.
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
A minimum of three to five years' experience processing first dollar medical claims or stop loss claim processing
Knowledge of Stop Loss Claims and Stop Loss industry preferred
Overall knowledge of health care industry
Proficiency using the Microsoft Office suite of products

At our company, we are committed to pay transparency and equity. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. Join our talent community to stay connected until the time is right for you!

We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.
At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We're proud to be recognized in our communities as a top employer. Visit our website to learn more about our benefits and recognition within our communities.
We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. For applicants residing in California, please read our employee California Privacy Policy and Notice.
Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Claims - Health & Dental