Senior Clinical Risk & Claims Strategist

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

Benefits offered by this job

Comprehensive benefits

401(k) employer match

Job summary

Sun Life U.S. is a leading provider of employee and government benefits, with about 50 million Americans accessing care and coverage.

The Senior Clinical Risk Consultant will review medical claims, underwriting prospects, and renewals to recommend cost-effective care in the best setting. This hybrid role requires clinical nursing expertise, prior Medical Stop Loss experience, and strong collaboration with claims, underwriting, and sales teams to identify cost savings and improve outcomes.

Qualifications

• Requires active RN license and 5+ years of clinical nursing experience.
• Experience with Medical Stop Loss or complex clinical case management in health insurance.
• Ability to work with diverse teams and manage confidential information.

Responsibilities

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

Skills

Analytical thinking

Interpersonal skills

Cost containment

Independent decision-making

Diversity collaboration

Education

Registered Nurse license

Job description

Sun Life U.S. is a leading provider of employee and government benefits, with about 50 million Americans accessing care and coverage.

The Senior Clinical Risk Consultant will review medical claims, underwriting prospects, and renewals to recommend cost-effective care in the best setting. This hybrid role requires clinical nursing expertise, prior Medical Stop Loss experience, and strong collaboration with claims, underwriting, and sales teams to identify cost savings and improve outcomes.