Senior Consultant, Supplemental Health

Sun Life•Portland, ME

5d•Hybrid

About The Position

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Internal candidates are not required to relocate near an office. The opportunity: We are seeking a highly organized and detail-oriented Senior Consultant, Supplemental Health Claims. In this role you will be responsible for processing and adjudicating supplemental health insurance claims in accordance with company policies and regulatory guidelines. Your primary objective will be to ensure accurate and timely claim payments, while providing exceptional customer service to policyholders. In addition, you will serve as a leader and go to resource for the team to ensure accuracy and the highest level of service for Clients.

Requirements

Ability to work with a diverse range of people.
5+ years of experience in supplemental health insurance claims processing or medical billing.
Strong knowledge of medical terminology, coding systems (e.g., ICD-10, CPT), and claim adjudication processes.
Familiarity with healthcare industry regulations, including HIPAA and state insurance laws.
Excellent analytical skills and attention to detail to accurately review and evaluate claim information.
Proficient in using claims management software and other computer applications.
Exceptional organizational and time management skills to prioritize workload and meet deadlines.
Excellent written and verbal communication skills to effectively interact with policyholders, providers, and internal stakeholders.
Ability to work independently and as part of a team, demonstrating flexibility and adaptability in a fast-paced environment.
Strong problem-solving skills, with the ability to resolve claim-related issues effectively and efficiently.
Commitment to delivering outstanding customer service and maintaining high levels of professionalism.
Ability to attain and maintain appropriate TPA licenses in accordance with the Claims Licensing Policy

Responsibilities

Review and evaluate supplemental health insurance claims for eligibility, completeness, and accuracy.
Verify policy information, coverage details, and any applicable endorsements or riders.
Adjudicate claims using established guidelines and company policies.
Determine the accuracy of medical coding, diagnostic information, and procedure documentation.
Request any necessary additional information or documentation from policyholders or healthcare providers.
Collaborate with the claims team to investigate and resolve any complex or disputed claims.
Ensure that claims are processed and paid in compliance with industry regulations and internal procedures.
Update claim status and maintain detailed and accurate records of all claim activities.
Communicate claim decisions, payment details, and any additional requirements to policyholders and healthcare providers.
Respond to inquiries and provide exceptional customer service to resolve any claim-related issues or concerns.
Stay updated on industry trends, regulatory changes, and best practices in supplemental health insurance claims processing.
Perform quality assurance reviews and mentor other Claims Consultants by providing feedback and identifying development opportunities with staff and management.
Evaluate current processes for efficiency and effectiveness
Provide manager support by assisting with decision making and problem-solving