Claims Investigation Services Senior Consultant
Sun Life · Portland, United States +2 · 1d ago
Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.
At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.
When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.
Job Description:
The Senior Consultant, Claims Investigation Services (CIS) is responsible for department quality control and audit responsibilities in addition to leading complex investigations involving suspected fraud, abuse, misrepresentation, provider misconduct, and other irregular claim activity across Sun Life U.S. Supplemental Health products, including Accident, Critical Illness, Cancer and Hospital Indemnity.
Preferred skills
- Serve as the subject matter expert for Supplemental Health fraud investigations.
- Train claims professionals to identify fraud indicators and escalation triggers.
- Provide consultation and guidance on suspicious claims.
- Develop investigation playbooks, reference materials, and best practices.
- Foster awareness of fraud risks across Claims Operations.
Qualifications
- Bachelor's degree or equivalent experience.
- Strong analytical and problem-solving skills.
- Experience reviewing medical records and claim documentation.
- Ability to conduct complex investigations independently.
- Strong written and verbal communication skills.
- Experience presenting findings to senior leadership.
Responsibilities
Claims Investigations
- Lead investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation, or organized fraud schemes.
- Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information, and payment history.
- Analyze claim activity to identify unusual patterns, trends, or indicators of fraud.
- Develop and execute investigation plans based on risk, complexity, and financial exposure.
- Determine appropriate investigative actions and escalation paths.
- Document investigative findings, recommendations, and outcomes.
Quality Audit & Claims Procedure Oversight
- Conduct quality audits of staff-processed claims to ensure consistent and accurate application of claim department guidelines, procedures, policy provisions, and benefit adjudication standards.
- Identify quality trends, error patterns, process gaps, and coaching opportunities that may impact claim accuracy, timeliness, member experience, or operational consistency.
- Provide audit findings, feedback, and recommendations to Claims Operations leaders to support staff development, procedural alignment, and continuous improvement.
- Maintain audit documentation and reporting to support quality control oversight, management review, and adherence to internal claim handling requirements.
Fraud Detection & Analytics
- Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies.
- Identify high-risk claims through:
- Claims frequency analysis
- Repeat provider patterns
- Repeat member behavior
- Injury and diagnosis trends
- Geographic anomalies
- Payment concentration analysis
- Prioritize investigation inventory using risk-scoring methodologies.
- Quantify financial exposure and recoverable amounts.
- Identify emerging fraud schemes and recommend mitigation strategies.
Medical Record & Evidence Review
- Coordinate medical record procurement and evidence gathering activities.
- Validate submitted documentation against provider records.
- Evaluate claim eligibility, diagnosis validity, treatment patterns, and supporting evidence.
- Identify inconsistencies between claim submissions and medical records.
- Work with internal clinical resources as necessary to assess medical appropriateness and validity.
Regulatory, Legal & Compliance Support
- Partner with Legal, Compliance, Risk Management, and SIU to ensure investigations comply with applicable laws and regulations.
- Prepare investigation summaries and supporting materials for internal and external reviews.
- Support regulatory inquiries, audits, legal proceedings, and fraud reporting requirements.
- Maintain investigation documentation consistent with company protocols and legal requirements.
Fraud Prevention & Program Development
- Develop proactive fraud prevention strategies for Supplemental Health.
- Identify process vulnerabilities that may enable fraudulent activity.
- Recommend policy, workflow, automation, and control enhancements.
- Partner with Product, Operations, and Technology leaders on fraud mitigation initiatives.
- Support enhancement of fraud monitoring tools and investigative capabilities.
Training & Expertise
- Serve as the subject matter expert for Supplemental Health fraud investigations.
- Train claims professionals to identify fraud indicators and escalation triggers.
- Provide consultation and guidance on suspicious claims.
- Develop investigation playbooks, reference materials, and best practices.
- Foster awareness of fraud risks across Claims Operations.
Salary Range: $72,500 - $108,800
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.
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We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.
Life is brighter when you work at Sun Life
At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We’re proud to be recognized in our communities as a top employer. Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.
We will make reasonable accommodations 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.
For applicants residing in California, please read our employee California Privacy Policy and Notice.
We do not require or administer lie detector tests as a condition of employment or continued employment.
Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.
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.
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