About the role

Senior Consultant processing and adjudicating supplemental health insurance claims at Sun Life. Ensuring accurate claims payments and providing exceptional customer service to policyholders.

Responsibilities

Review and evaluate supplemental health insurance claims for eligibility, completeness, and accuracy
Verify policy information, coverage details, and any applicable endorsements or riders
Adjudicate claims using established guidelines and company policies
Determine the accuracy of medical coding, diagnostic information, and procedure documentation
Request any necessary additional information or documentation from policyholders or healthcare providers
Collaborate with the claims team to investigate and resolve any complex or disputed claims
Ensure that claims are processed and paid in compliance with industry regulations and internal procedures
Update claim status and maintain detailed and accurate records of all claim activities
Communicate claim decisions, payment details, and any additional requirements to policyholders and healthcare providers
Respond to inquiries and provide exceptional customer service to resolve any claim-related issues or concerns
Stay updated on industry trends, regulatory changes, and best practices in supplemental health insurance claims processing
Perform quality assurance reviews and mentor other Claims Consultants by providing feedback and identifying development opportunities with staff and management
Evaluate current processes for efficiency and effectiveness
Provide manager support by assisting with decision making and problem-solving

5+ years of experience in supplemental health insurance claims processing or medical billing
Strong knowledge of medical terminology, coding systems (e.g., ICD-10, CPT), and claim adjudication processes
Familiarity with healthcare industry regulations, including HIPAA and state insurance laws
Excellent analytical skills and attention to detail to accurately review and evaluate claim information
Proficient in using claims management software and other computer applications
Exceptional organizational and time management skills to prioritize workload and meet deadlines
Excellent written and verbal communication skills to effectively interact with policyholders, providers, and internal stakeholders
Ability to work independently and as part of a team, demonstrating flexibility and adaptability in a fast-paced environment
Strong problem-solving skills, with the ability to resolve claim-related issues effectively and efficiently
Commitment to delivering outstanding customer service and maintaining high levels of professionalism
Ability to attain and maintain appropriate TPA licenses in accordance with the Claims Licensing Policy

Health insurance
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 that supports career growth