Senior Clinical Risk Consultant

Employment Type

: Full-Time


: Miscellaneous

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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 Lifes 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.


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

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