Consultant, Ocean Modeler
ERM
Python
Senior Consultant, Supplemental Health
Sun Life
full-time
Posted on:
Location Type: Hybrid
Location: Baltimore • Connecticut, Maine, Maryland • 🇺🇸 United States
Visit company websiteSalary
💰 $71,100 - $106,700 per year
Job Level
Senior
About the role
- 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
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical codingICD-10CPTclaim adjudicationclaims processingmedical billingclaims management softwareanalytical skillsattention to detailquality assurance
Soft skills
organizational skillstime managementwritten communicationverbal communicationproblem-solvingcustomer serviceflexibilityadaptabilityteamworkindependence
Certifications
TPA licenses
