Senior Clinical Risk Consultant

Sun Life; Baltimore (MD); Híbrido; USD 79 000 - 118 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Generous vacation and sick time

401(k) match

Company paid life and AD&D insurance

Resumo da oferta

Sun Life U.S. is a leading provider of employee and government benefits, offering dental, vision, life, disability, and medical coverage.

The Senior Clinical Risk Consultant will review medical claims, underwriting prospects, and renewals, applying clinical expertise to recommend cost-effective care in the appropriate setting. This hybrid role requires an active RN license, 5+ years of clinical nursing experience, and experience with medical stop loss or complex case management.

Qualificações

• Active RN license is required.
• 5+ years of clinical nursing experience is required.
• Prior Medical Stop Loss experience or 3+ years of complex clinical case management experience in medical, workers' compensation, or another health insurance setting is preferred.
• Ability to review medical claims, identify cost savings opportunities, and coordinate with multiple stakeholders.

Responsabilidades

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

Conhecimentos

Independent analytical thinking

Organizational skills

Decision making

Formação académica

RN license (Active)

Descrição da oferta de emprego

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.

Job Description:

Sun Life embraces a hybrid work model that balances in‑office collaboration with the flexibility of virtual work in the contiguous states plus AK.

The opportunity: In the Senior Clinical Risk Consultant role, you will use prior medical knowledge and research capabilities to help individuals understand what medical treatments are needed, or may be needed in the future, and determine what treatments would cost. You will use your extensive knowledge, medical expertise, and professional experience to review claims, underwriting prospects and renewals to recommend the best possible care, for an appropriate cost, in the best possible setting. This position requires an understanding of medical insurance and is non‑patient facing.

How you will contribute:

• Use technical expertise and clinical experience to coordinate with senior management, claims specialists, underwriting, sales team, and TPAs to review medical claims for appropriateness, identify cost savings opportunities, and assess potential risk.
• Investigate and negotiate medical and prescription charges, suggest care alternatives, and identify billing errors for potential cost savings opportunities.
• Review complex medical treatment plans for appropriateness and coverage, including treatments such as transplants, CAR‑T therapies, and up‑and‑coming gene therapies.
• Create and facilitate educational presentations for a variety of internal and external audiences.

What you will bring with you:

• Ability to work with a diverse range of people
• Active Registered Nurse license
• 5+ years of clinical nursing experience is required
• Prior Medical Stop Loss insurance experience or 3+ years of complex clinical case management experience in medical, workers' compensation, or another health insurance setting
• A passion for helping people, especially in times of need due to illness or injury
• Your desire and ability to provide superior service and build and maintain positive relationships
• Independent analytical thinking, organizational, and decision‑making skills.
• Excellent working knowledge of current medical conditions and treatment plans, including but not limited to an understanding of organ and tissue transplantation, oncology, cardiac or other critical illness

Salary:

$78,600-$117,900

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.

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 accommodation to the known physical or mental limitation 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 [e-mail] 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.

Job Category:

Claims - Clinical

Posting End Date:

25/10/2026