Senior Clinical Risk Strategist

Sun Life; Portland (ME); Hybrid; USD 79,000 - 118,000; Full time

Job summary

Sun Life U.S. is a leading provider of employee and government benefits, offering comprehensive coverage across medical, dental, vision, and more. The Senior Clinical Risk Consultant will review medical claims, assess treatment plans, and advise on cost-effective care options in a non-patient facing role.

This position supports a hybrid work model in the contiguous states plus AK. The role requires an active RN license and 5+ years of clinical nursing experience, with prior medical stop loss or

Qualifications

• Active Registered Nurse license.
• 5+ years of clinical nursing experience.
• Prior Medical Stop Loss insurance experience or 3+ years of complex clinical case management experience in medical, workers' compensation, or another health insurance setting.
• Ability to work with a diverse range of people.
• Independent analytical thinking, organizational, and decision-making skills.
• Excellent knowledge of current medical conditions and treatment plans, including organ/tissue transplantation, oncology, and cardiac illnesses.

Responsibilities

• Coordinate with senior management, claims specialists, underwriting, sales team, and TPAs to review medical claims for appropriateness.
• 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

Active RN license

Clinical nursing experience

Medical stop loss experience

Analytical thinking

Communication skills

Job description

Sun Life U.S. is a leading provider of employee and government benefits, offering comprehensive coverage across medical, dental, vision, and more. The Senior Clinical Risk Consultant will review medical claims, assess treatment plans, and advise on cost-effective care options in a non-patient facing role.

This position supports a hybrid work model in the contiguous states plus AK. The role requires an active RN license and 5+ years of clinical nursing experience, with prior medical stop loss or