Consultant facilitating operational excellence and execution management for various client contexts. Engaging in projects to enhance operational performance and deliver value reliably.
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
Requirements
- 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
Benefits
- 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
Job title
Job type
Experience level
Salary
Degree requirement
No Education Requirement
Location requirements
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