Senior Clinical Risk Consultant

About the role

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. At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful. When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

Responsibilities

• 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.
• Use extensive 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.
• 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.

Requirements

• 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

Skills

• Ability to work with a diverse range of people
• Passion for helping people, especially in times of need due to illness or injury
• 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 organ and tissue transplantation, oncology, cardiac or other critical illness

Benefits

• Generous vacation and sick time
• Market-leading paid family, parental and adoption leave
• Medical coverage
• Company-paid life and AD&D insurance
• Disability programs
• Partially paid sabbatical program
• 401(k) employer match
• Stock purchase options
• Employer-funded retirement account
• Flexible, inclusive and collaborative work environment supporting career growth
• Recognized as a top employer; Great Place to Work® Certified in Canada and the U.S.; Boston Globe “Top 10” employer for two consecutive years

Pay

Salary range: $78,600–$117,900. Eligible for a discretionary annual incentive award based on individual performance and overall business performance.

Schedule

Hybrid work model balancing in-office collaboration with the flexibility of virtual work in the contiguous states plus Alaska.