Senior Clinical Risk and Cost Optimization Consultant

Sun Life Financial; Wellesley (MA); Hybrid; USD 79,000 - 118,000; Full time

Job summary

Sun Life Financial seeks a Senior Clinical Risk Consultant to apply medical knowledge and research to review claims, underwriting prospects, and renewals for appropriate, cost-effective treatment options. This non-patient facing role requires RN licensure and deep insurance industry experience.

The candidate will coordinate with senior management, claims specialists, underwriting, and TPAs to optimize costs, investigate charges, and present educational content to diverse audiences.

Qualifications

• Active RN license is required.
• 5+ years of clinical nursing experience are required.
• Experience with Medical Stop Loss or 3+ years of complex clinical case management in health insurance.
• Strong communication and stakeholder-management skills.
• Knowledge of transplantation, oncology, and cardiac conditions.

Responsibilities

• Review medical claims for appropriateness and cost.
• Identify cost savings opportunities and negotiate charges.
• Review complex treatment plans including transplants, CAR-T, and gene therapies.
• Coordinate with senior management, claims specialists, underwriting, sales team, and TPAs.
• Create and deliver educational presentations for internal and external audiences.

Skills

RN license

Clinical nursing

Claims review

Analytical thinking

Education

Active RN license

Job description

Sun Life Financial seeks a Senior Clinical Risk Consultant to apply medical knowledge and research to review claims, underwriting prospects, and renewals for appropriate, cost-effective treatment options. This non-patient facing role requires RN licensure and deep insurance industry experience.

The candidate will coordinate with senior management, claims specialists, underwriting, and TPAs to optimize costs, investigate charges, and present educational content to diverse audiences.