Sun Life Financial Quality Assurance Analyst - Stop Loss in Wellesley Hills, Massachusetts

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Job Description:

This position reports to the Stop Loss Claims AVP and is responsible for managing Quality Assurance review of Stop Loss claims, including providing process improvements across the Wellesley, Windsor and telework sites. The responsibilities include: complete evaluation of claim adjudication, training, monthly reporting as well as coordination with internal Overpayment Specialist to ensure the successful recovery of overpaid funds, either directly or by hiring vendors to recoup the money.

This position is responsible for the management of $845 million in paid claims yearly across multiple locations. The decisions and interaction with Claims, Actuarial, Underwriting and SOX play an integral part in managing the business.

Specifically, this position is responsible for the evaluation, investigation, communication and reporting of catastrophic complex claims, ensuring all claims are paid accurately with feedback provided the claims area, within the set turnaround time guidelines.

Responsibilities:

  • Conduct thorough evaluations of department and examiner-specific claim adjudications

  • Review the application of contractual provisions to recapture any inappropriately paid funds

  • Provide the Stop Loss manager with information to assist in the assessment of the skills & knowledge of each examiner

  • Responsible for delivering specific reviews of each specialist’s claim work. These reviews verify the time standards of certain activities, the financial accuracy of the work, and the overall quality of the block of claims

  • Initiate communication with the Stop Loss manager that identifies issues with current, real time financial impact, such as incorrect calculations or incomplete compliance with offset protocols, or the claim specialists’ management of overpayments in addition to application and adherence to claims adjudication policy & procedures, noting any individual or team deficiencies.

  • Monitor selected claims according to Sarbanes – Oxley guidelines to verify that the claims examiner has validated the financial aspects of the claim and to verify proper funds were not adjudicated inappropriately

  • Maintain the daily quality assurance of all claims being adjudicated in both claims systems – Includes accuracy of the information along with financial accuracy of the entry

  • Updating, correcting, testing & implementing any and all changes into both claim systems

  • Auditing Front End data entries, daily – report findings to Claims Services for corrective action

  • Oversee review of 100% checks dispatched – issue voids and reissues if applicable

  • Maintain Records Retention for Stop Loss claims and Operations

  • Overpayments – Notify the Claims Overpayment Specialist of an overpayment - tracking, documenting and recovery of said funds by applying the appropriate contractual provisions of the contract

Responsible to complete quarterly, weekly and daily reports for SOX and are required to document findings for distribution to the Stop Loss Claims Management/Officer/Director

  • QC Audit appeals with Stop Loss management

  • Deliver fair and accurate assessments of the quality of the claims work specialists

  • It requires the ability to objectively review and assess the facts of the each individual claim

  • Having the technical knowledge and appreciation of the uniqueness of each claim situation gained only through experience

  • The ability to communicate positive and negative findings in a manner that is conducive to improve skills by the claims examiner

  • Provides clarity regarding stop loss procedures and processes, and recommends change when appropriate

  • Offers constructive solutions to the managers, for improvements of their teams

  • Handling relations between Policy Holders, TPAs and brokers when there is a conflict with overpayments

    Requirements:

  • Bachelor’s degree or equivalent work experience

  • 6-8 years of experience in the financial services industry

  • 3-4 years of experience working in Stop Loss claims and/or Stop Loss underwriting

  • Ability to understand and interpret client plan documents as well as Stop Loss policies

  • Broad knowledge of Stop Loss Insurance products and processes.

  • Ability to think creatively to resolve the more complex or non-routine issues

  • Strong written and verbal communication skills and experience

  • Ability to effectively coach, develop and motivate team member to achieve Department and SLF goals

  • Strong negotiation, decision making and problem solving skills and experience

  • Ability to develop and maintain effective, professional business relationships across all levels of the organization and external TPA administrators and customers

  • Accountable for contributing to a workplace environment that fosters mutual respect, cooperation, information sharing and commitment to delivering the expected service and financial results

  • Strong PC Proficiency

  • Ability to successfully meet deadlines and achieve goals

  • Knowledge of company computer systems and products a strong plus

Sun Life Financial is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law. Sun Life Financial is committed to building a diverse and inclusive company culture.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter – for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.

Job Category:

Claims - Life & Disability

Posting End Date: