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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in processing Stop Loss claims and applying contractual provisions while ensuring compliance with regulatory guidelines such as HIPAA and the Affordable Care Act. Strong communication and negotiation skills are essential for effective claim management and customer service.
Highest-signal resume keywords
Stop Loss Claims ProcessingContractual Provisions ApplicationRegulatory Compliance (HIPAA, ACA)Negotiation and Persuasion SkillsMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingContract AnalysisMedical-Record AnalysisCost-Containment InitiativesAction Plan Development
Soft Skills
Team CollaborationWritten CommunicationVerbal CommunicationFlexibilityProfessionalism
Industry Keywords
Health Care IndustryEligibility DeterminationFinancial Risk ManagementCustomer ServiceLegal Risk Assessment
About the role
Key responsibilities & impact- Determine the eligibility of assigned claims by applying contractual provisions to medical facts and claim specifications
- Apply contractual provisions from the underlying plan and Sun Life contract, especially regarding eligibility and exclusions
- Maintain claim block and meet departmental production and quality metrics
- Prepare written rationale for claim decisions based on contract provisions, plan specifications, and medical-record analysis
- Apply legal risk and regulatory/statutory guidelines, including HIPAA, privacy, and Affordable Care Act requirements
- Determine when and how internal and external medical, investigative, and legal resources add value
- Establish cooperative and productive relationships with professional resources
- Develop, coordinate, and implement action plans for accepted claims
- Ensure effective claim management and implementation of cost-containment initiatives with clinical resources
- Provide customer service and manage financial risk associated with assigned Stop Loss claims
Requirements
What you’ll need- 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
Benefits
Comp & perks- Generous vacation and sick time
- Market-leading 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
- Discretionary annual incentive award based on individual and business performance