Stop Loss Claims Resolution Consultant

Claims Resolution Consultant

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.
• Research and resolve advanced claim inquiries by analyzing claim history, medical documentation, reimbursement data, plan documents, and Sun Life stop-loss contract provisions.
• Interpret and apply contractual language consistently, identifying when issues require escalation, exception handling, or clinical, legal, or investigative review.
• Provide consultative guidance to requestors on claim status, required documentation, anticipated timelines, and next steps.
• Own inquiries from intake through closure, ensuring accountability, tracking, and follow-up.
• Acknowledge inquiries promptly, provide clear expectations for updates and resolution timing, and proactively communicate if timelines change.
• Deliver clear, concise, and customer-appropriate written communication (primarily email) that summarizes findings, decisions, and supporting rationale.
• Identify inquiries that require adjudication or reimbursement review and route to appropriate Claims Analysts or Senior Analysts with complete and organized handoffs.
• Partner collaboratively with internal teams including Claims, Overpayments, Client Management, Sales, Clinical Resources, and Legal to support accurate and timely outcomes.
• Participate in client implementation, onboarding, or issue-resolution calls as needed, explaining stop loss claim processes and outcomes clearly.
• Document research, decisions, communications, and handoffs thoroughly in the system of record.
• Ensure all claim handling complies with privacy, security, and regulatory requirements (HIPAA, etc.).
• Apply sound claim practices and professional judgment to identify trends, risks, or recurring issues impacting customer experience or operational efficiency.
• Act as a go-to resource for peers and partners by sharing expertise on stop loss claim handling, documentation standards, and common contract provisions.
• Identify opportunities for process improvements, enhanced job aids, or clearer communication templates based on inquiry volume and trends.
• Contribute 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.
• Experience reviewing and supporting complex or large loss stop loss claims end-to-end.
• Strong ability to interpret and explain plan documents and contract provisions.
• Demonstrated experience navigating claims systems, reporting, and internal knowledge resources.
• Excellent written and verbal communication skills, with the ability to explain complex claim matters to non-technical audiences.
• Strong organizational skills with the ability to manage multiple priorities and maintain detailed records through resolution.
• Proven judgment in identifying when issues require escalation and how to route them effectively.
• 35+ years of experience in medical claims processing and/or stop loss claims, including exposure to large-loss or complex claims.
• Experience supporting TPAs, brokers, employers, or sales partners in a consultative or service-based role.
• Familiarity with overpayment concepts, reimbursement troubleshooting, and coordination with clinical or investigative resources.
• Experience contributing to job aids, playbooks, or process improvement initiatives.
• Advanced analytical and problem-solving skills
• Strong customer-focused service orientation
• Professional judgment and discretion with sensitive information
• Clear, confident communication and documentation
• Collaboration across operational and clinical teams
• Accountability for outcomes and follow-through
• Continuous 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.

We will make reasonable accommodation 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.com to request an accommodation.

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.