Senior Medical Risk & Claims Advisor - Hybrid

Sun Life; Hartford (CT); Hybrid; USD 79,000 - 118,000; Full time

Benefits offered by this job

Generous vacation and sick time

401(k) employer match

Discretionary annual incentive

Job summary

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to apply medical knowledge and review claims, underwriting prospects, and renewals to recommend cost‑effective care in the best setting.

The role is non‑patient facing and requires understanding of medical insurance in a hybrid model across the contiguous states plus AK. You will work with claims, underwriting, sales, and TPAs to review medical claims, negotiate charges, and identify cost savings, including complex plans such as

Qualifications

• 5+ years of clinical nursing experience required.
• Prior Medical Stop Loss experience or 3+ years of complex clinical case management in health insurance.
• Ability to work with a diverse range of people.
• Independent analytical thinking, organizational, and decision‑making skills.
• Knowledge of current medical conditions and treatment plans including transplantation, oncology, cardiac, or other critical illnesses.

Responsibilities

• Coordinate with senior management, claims specialists, underwriting, sales, and TPAs to review medical claims for appropriateness and identify cost savings opportunities.
• Investigate and negotiate medical and prescription charges, suggest care alternatives, and identify billing errors for potential cost savings.
• 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

Clinical nursing experience

Analytical thinking

Organizational skills

Decision making

Education

Registered Nurse license

Job description

Sun Life U.S. is seeking a Senior Clinical Risk Consultant to apply medical knowledge and review claims, underwriting prospects, and renewals to recommend cost‑effective care in the best setting.

The role is non‑patient facing and requires understanding of medical insurance in a hybrid model across the contiguous states plus AK. You will work with claims, underwriting, sales, and TPAs to review medical claims, negotiate charges, and identify cost savings, including complex plans such as