Sun Life Financial Senior Clinical Risk Consultant in Wellesley Hills, Massachusetts

At Sun Life, we work together, share common values and encourage growth and achievement. We offer many career paths that attract a wide variety of talent and skills. Follow a path that lets your talents shine.

Job Description:

In this role, you will use your extensive knowledge, expertise and experience to review claims, underwriting prospects and renewals to identify Stop-Loss cost savings opportunities.

This position requires an understanding of medical insurance and is non-patient facing.

  • Responsible for review of claims and underwriting prospects and renewals for cost savings opportunities in the Stop-Loss department utilizing extensive knowledge, expertise and experience.

  • Responsible for review of case management reports, notices and verbal communications to identify cost savings opportunities.

  • Responsible for medical claims reviews.

  • Reviews underwriting files utilizing technical expertise and consults with underwriting to assist in identifying potential future medical risk.

  • Consults with underwriters to assist in determining potential future medical risk.

  • Provides technical expertise to Stop-Loss senior management, claims adjudicators, underwriting, sales force, TPAs, and their case managers

  • Provide information regarding Sun Life's SunExcel/SunSource programs.

  • Develop and maintain strong relationships with internal/external parties, vendors and case managers.

  • Reviews and advises claims staff regarding the medical appropriateness of claims.

  • Reviews medical claims for cost savings opportunities using established guidelines.

  • Reviews underwriting files utilizing technical expertise.

  • Provides information, cost savings, risk management reporting and cost containment strategies for assigned cases.

  • Review transplants for medical appropriateness and coverage. Set up transplant cost savings contracts.

  • Utilizing the Current claims and documentation resources, keeps confidential information.

Requirements

  • Registered Nurse with professional approach and ability to work independently, essential.

  • An in-depth knowledge of the Case Management process with, and an RN with at least 5 years clinical experience.

  • Knowledge of Stop Loss with the ability to interpret policy language preferred.

  • Must be able to utilize reference materials and comprehend medical terminology.

  • Strong professional relationship building skills

  • Must have strong analytical, organization and decision making skills and a business orientation.

  • Must have excellent working knowledge of current medical conditions and treatment plans, including but not limited to an understanding of organ and tissue transplantation, oncology, cardiac or other critical illness in necessary.

  • Ability to read, analyze and interpret medical records, claims files and underwriting reports.

  • Ability to effectively present information and respond to questions from internal and external customers.

  • Excellent verbal and written communication skills

  • Ability to multitask and accept rapid change.

  • Background in Medical Insurance Case Management preferred

Sun Life Financial is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law. Sun Life Financial is committed to building a diverse and inclusive company culture.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter – for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.

Job Category:

Claims - Health & Dental

Posting End Date: