Claims Analyst, Health and Risk Solutions

Sun Life

. Review claims, interpret and compare contracts, disperse reimbursement, and ensure required documentation supports Stop Loss claim determinations .

Posted 9/23/2026full-timeUnited StatesMid-LevelSenior💰 $54,100 - $81,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims management, applying contractual provisions, and ensuring compliance with regulatory guidelines such as HIPAA and the Affordable Care Act. Strong ability to analyze medical records and develop action plans for effective claim resolution.

Highest-signal resume keywords

Claims ManagementContractual Provisions ApplicationRegulatory ComplianceCustomer ServiceNegotiation Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalysisMedical Record AnalysisCost-Containment InitiativesAction Plan DevelopmentClaim Eligibility Determination

Soft Skills

NegotiationPersuasionTeam CollaborationProfessionalismCommunication Skills

Tools & Technologies

Microsoft Office Suite

Industry Keywords

Health Care IndustryStop Loss ClaimsHIPAAAffordable Care ActFinancial Risk Management

About the role

Key responsibilities & impact

Review claims, interpret and compare contracts, disperse reimbursement, and ensure required documentation supports Stop Loss claim determinations
Provide customer service and manage the financial risk associated with an assigned block of Stop Loss claims
Apply contractual provisions, underlying plan specifications, professional case management resources, and claims practices to medical facts to decide reimbursement or denial
Develop, coordinate, and implement an action plan for each accepted claim
Ensure claims are managed effectively and cost-containment initiatives are implemented with clinical resources
Determine claim eligibility by applying contractual provisions to medical facts and claim specifications
Maintain claim blocks and meet departmental metrics
Prepare written rationales for claim decisions based on contracts, plan specifications, and medical-record analysis
Apply legal risk and regulatory/statutory guidelines, including HIPAA, privacy, and the Affordable Care Act
Identify and coordinate internal and external medical, investigative, and legal resources
Establish cooperative and productive relationships with professional resources

Requirements

What you’ll need

Overall knowledge of the health care industry
Demonstrated success in negotiation, persuasion, and solutions-based underwriting
Ability to work in a fast-paced, high-volume environment
Flexibility to handle multiple priorities while maintaining a high level of professionalism
Demonstrated ability to work as part of a cohesive team
Strong written and verbal communication skills
Proficiency using the Microsoft Office suite of products
Ability for occasional travel
Bachelor's degree preferred

Benefits

Comp & perks

Generous vacation and sick time
Paid family, parental and adoption leave
Medical coverage
Company-paid life and AD&D insurance
Disability programs
Partially paid sabbatical program
401(k) employer match
Stock purchase options
Employer-funded retirement account
Flexible, inclusive and collaborative work environment
Career growth support
Reasonable accommodations for qualified individuals with disabilities or special disabled veterans