Stop Loss & Health Claim Analyst

About the role

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. How you will contribute: 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 What you will bring with you: 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 Salary: Salary Range: $54,100 - $81,200 At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. 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. We are dedicated to creating a work environment where everyone is rewarded for their contributions. Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you! We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. 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. Life is brighter when you work at Sun Life 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 c