Senior Clinical Risk Strategist - Hybrid

Sun Life; Baltimore (MD); Hybrid; USD 79,000 - 118,000; Full time

Benefits offered by this job

Generous vacation and sick time

401(k) match

Company paid life and AD&D insurance

Job summary

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.

Qualifications

• 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.

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 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.

Skills

Independent analytical thinking

Organizational skills

Decision making

Education

RN license (Active)

Job description

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.