Case Specialist, Supplemental Health at Sun Life Financial (U.S.) Services Company, Inc. — Portland, ME

Job Description

The opportunity:

The Case Specialist, Supplement Health Claims manages initial liability claims submitted for Critical Illness, Cancer, Hospital Indemnity and Accidental claims. They work independently and autonomously managing each claim by conducting a thorough review and investigation, determining what additional resources are appropriate to collaborate with and deciding the initial and future liability of each claim.

How you will contribute:

• Reviews and investigates Critical Illness, Cancer, Hospital Indemnity and Accidental claims by using the telephone and written contact with the applicable parties, e.g. claimant, employer, treating physicians and client carrier partner, to gather pertinent data to analyze each claim.
• Investigates the claim level eligibility by accessing the client carriers’ systems.
• Resolves eligibility issues by collaborating with employers and partners at the client company.
• Adjudicates claims and benefits accurately and fairly, in accordance with the contract, appropriate policies and procedures, and state and federal regulations, while meeting productivity and quality standards.
• Utilizes clinical staff, adhering to referral policies.
• Conducts in-depth pre-existing condition reviews and contestable investigations.
• Thoroughly reviews all medical records and additional information submitted to accurately calculate and communicate all benefits payable in a timely manner.
• Develops and maintains online claims data.
• Interprets, understands, and communicates the policy that governs each claim.
• Mentors and trains new hires as requested.

What you will bring with you:

• Minimum 1-year previous work experience in financial, medical, and/or customer service field
• High School Diploma required; college degree preferred
• Experience in Supplemental Health, Case Administrator role preferred Attains and maintains appropriate TPA licenses in accordance with the Claims Licensing Policy
• Solid analytical, critical thinking, problem solving and decision-making skills
• Ability to interpret and communicate contract language
• Excellent verbal communication skills, with the ability to be both pleasant and professional
• Strong written communication skills
• Solid mathematical skills
• Ability to work well independently and in a team environment
• Strong interpersonal and customer service skills
• Ability to initiate and prioritize regular work duties and projects
• Detail oriented, organized, the ability to multi-task, and strong time management skills
• Strong computer skills, proficient in a PC environment and MS Word, Excel, and email systems
• Ability to work professionally and effectively with co-workers, clients, claimants, vendors, and others with whom FullscopeRMS does business

Salary Range: $55,300 - $83,000

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.

Job Category:

Claims - Life & Disability

Posting End Date:

13/08/2026