Senior Clinical Risk Consultant - Medical Claims & Cost Optimization

Sun Life; Milwaukee (WI); Hybrid; USD 79,000 - 118,000; Full time

Benefits offered by this job

Comprehensive benefits

401(k) match

Generous PTO and paid family leave

Job summary

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to apply medical knowledge to review claims, underwriting prospects, and renewals, aiming for appropriate, cost-effective care in a non-patient facing role.

You will collaborate with claims, underwriting, and sales teams to identify cost savings, evaluate complex treatment plans (transplants, CAR‑T, gene therapies), and prepare educational presentations for diverse audiences in a hybrid work environment.

Qualifications

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

Responsibilities

• Coordinate with senior management, claims specialists, 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, CAR‑T therapies, and gene therapies.
• Create and facilitate educational presentations for internal and external audiences.

Skills

RN license

Clinical nursing experience

Medical stop loss experience

Analytical thinking

Communication skills

Job description

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to apply medical knowledge to review claims, underwriting prospects, and renewals, aiming for appropriate, cost-effective care in a non-patient facing role.

You will collaborate with claims, underwriting, and sales teams to identify cost savings, evaluate complex treatment plans (transplants, CAR‑T, gene therapies), and prepare educational presentations for diverse audiences in a hybrid work environment.