Job Description:

The opportunity: The Claims Resolution Consultant serves as a subject matter expert in Stop Loss medical claims and is the primary point of contact for complex claim inquiries, escalations, and resolution support. This role combines deep technical expertise as a Stop Loss Health Claims Analyst with responsibility for managing end-to-end inquiry resolution, including research, claim determination support, documentation review, and clear customer communication. The Consultant independently resolves sophisticated inquiries related to claim eligibility, reimbursement status, documentation requirements, and contractual interpretation. They partner closely with Claims Analysts, Senior Analysts, clinical resources, and other internal teams to ensure accurate, timely, and supportable outcomes. This role requires strong judgment, advanced understanding of stop loss products, and the ability to explain complex claim matters clearly to TPAs, brokers, employers, sales partners, and internal stakeholders.

How you will contribute:

Serve as an expert resource for Stop Loss medical claims, including large-loss and complex claim scenarios, reimbursement determinations, exclusions, and eligibility issues.\nResearch and resolve advanced claim inquiries by analyzing claim history, medical documentation, reimbursement data, plan documents, and Sun Life stop-loss contract provisions.\nInterpret and apply contractual language consistently, identifying when issues require escalation, exception handling, or clinical, legal, or investigative review.\nProvide consultative guidance to requestors on claim status, required documentation, anticipated timelines, and next steps.\nOwn inquiries from intake through closure, ensuring accountability, tracking, and follow-up.\nAcknowledge inquiries promptly, provide clear expectations for updates and resolution timing, and proactively communicate if timelines change.\nDeliver clear, concise, and customer-appropriate written communication (primarily email) that summarizes findings, decisions, and supporting rationale.\nIdentify inquiries that require adjudication or reimbursement review and route to appropriate Claims Analysts or Senior Analysts with complete and organized handoffs.\nPartner collaboratively with internal teams including Claims, Overpayments, Client Management, Sales, Clinical Resources, and Legal to support accurate and timely outcomes.\nParticipate in client implementation, onboarding, or issue-resolution calls as needed, explaining stop loss claim processes and outcomes clearly.\nDocument research, decisions, communications, and handoffs thoroughly in the system of record.\nEnsure all claim handling complies with privacy, security, and regulatory requirements (HIPAA, etc.).\nApply sound claim practices and professional judgment to identify trends, risks, or recurring issues impacting customer experience or operational efficiency.\nAct as a go-to resource for peers and partners by sharing expertise on stop loss claim handling, documentation standards, and common contract provisions.\nIdentify opportunities for process improvements, enhanced job aids, or clearer communication templates based on inquiry volume and trends.\nContribute to a strong service culture through collaboration, follow-through, and a solutions-oriented mindset. What will you bring with you: Expert-level knowledge of Stop Loss medical claims, including eligibility determination, reimbursement workflows, documentation requirements, and contract interpretation.\nExperience reviewing and supporting complex or large loss stop loss claims end-to-end.\nStrong ability to interpret and explain plan documents and contract provisions.\nDemonstrated experience navigating claims systems, reporting, and internal knowledge resources.\nExcellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.\nStrong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.\nProven judgment in identifying when issues require escalation and how to route them effectively.\n3-5+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.\nExperience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.\nFamiliarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.\nExperience contributing to job aids, playbooks, or process improvement initiatives.\nAdvanced analytical and problem-solving skills\nStrong customer-focused service orientation\nProfessional judgment and discretion with sensitive information\nClear, confident communication and documentation\nCollaboration across operational and clinical teams\nAccountability for outcomes and follow-through\nContinuous improvement mindset

Salary Range:

$54,100 - $81,200 At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions. Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you! We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds. Life is brighter when you work at Sun Life 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. We're proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S., we've also been recognized as a \"Top 10\" employer by the Boston Globe's \"Top Places to Work\" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities. We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email thebrightside@sunlife.comto request an accommodation. For applicants residing in California, please read our employee California Privacy Policy and Notice. We do not require or administer lie detector tests as a condition of employment or continued employment. Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Category:

Claims -

Health & Dental Posting End Date:

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