Stop Loss & Health Claim Analyst

Sun Life Financial • Nashville, TN

53d

About The Position

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.

Requirements

• 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
• Overall knowledge of health care industry
• Proficiency using the Microsoft Office suite of products
• Ability to travel

Nice To Haves

• Knowledge of Stop Loss Claims and Stop Loss industry preferred
• Demonstrated success in negotiation, persuasion, and solutions-based underwriting

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

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Number of Employees: 5,001-10,000 employees