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Job description
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.
Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.
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 Supplementa
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Worksite address
portland, ME, 04122, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.