Hybrid Senior Clinical Risk Advisor

Sun Life; Nashville (TN); Hybrid; USD 79,000 - 118,000; Full time

Job summary

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to leverage medical knowledge and research skills to determine needed treatments and associated costs.

The role reviews claims, underwriting prospects and renewals to recommend cost-effective care in a non-patient-facing capacity. The position requires an active RN license, 5+ years of clinical nursing experience, and experience in complex case management or stop loss.

Qualifications

• Active Registered Nurse license.
• 5+ years of clinical nursing experience.
• Prior Medical Stop Loss or 3+ years of complex clinical case management in health insurance.

Responsibilities

• Coordinate with senior management, claims, underwriting, sales and TPAs to review medical claims for appropriateness and cost savings.
• Investigate and negotiate medical and prescription charges, suggest care alternatives and identify billing errors.
• Review complex medical treatment plans for appropriateness and coverage, including transplants and CAR‑T therapies.
• Create and facilitate educational presentations for internal and external audiences.

Skills

Registered Nurse

Clinical nursing

Analytical thinking

Communication

Job description

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to leverage medical knowledge and research skills to determine needed treatments and associated costs.

The role reviews claims, underwriting prospects and renewals to recommend cost-effective care in a non-patient-facing capacity. The position requires an active RN license, 5+ years of clinical nursing experience, and experience in complex case management or stop loss.