Claims Analyst, Health and Risk Solutions

Sun Life

. Review claims and determine eligibility for assigned claims .

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 review and eligibility determination, applying contractual provisions and medical facts while maintaining compliance with regulatory guidelines such as HIPAA and the Affordable Health Care Act. Strong communication and negotiation skills are essential for managing financial risk and developing cooperative relationships with stakeholders.

Highest-signal resume keywords

Claims ReviewEligibility DeterminationNegotiation SkillsRegulatory ComplianceCustomer Service

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProtocolsContract InterpretationReimbursement AnalysisMedical Record ReviewCost Containment Initiatives

Soft Skills

Written CommunicationVerbal CommunicationTeam CollaborationFlexibilityProfessionalism

Tools & Technologies

Microsoft Office Suite

Industry Keywords

Health Care IndustryStop Loss ClaimsLegal RiskStatutory GuidelinesAffordable Health Care Act

About the role

Key responsibilities & impact

Review claims and determine eligibility for assigned claims
Interpret and compare underlying plan and Sun Life contract provisions
Disperse reimbursement and determine reimbursement or denial
Ensure claims contain required documentation for Stop Loss claim determination
Provide customer service and manage financial risk for an assigned block of Stop Loss claims
Apply contractual provisions, underlying plan specifications, medical facts, case management resources, and claims protocols
Maintain the claim block and meet departmental metrics
Prepare written rationales for claim decisions based on contract, plan specifications, and medical records
Identify and use internal and external medical, investigative, and legal resources
Develop, coordinate, and implement action plans for accepted claims
Implement cost containment initiatives with clinical resources
Establish cooperative and productive relationships with professional resources

Requirements

What you’ll need

Overall knowledge of 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
Knowledge of legal risk and regulatory/statutory guidelines, including HIPPA, privacy, and Affordable Health Care Act

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
Annual discretionary incentive award based on individual and business performance