Senior Clinical Consultant

Employment Type

: Full-Time


: Scientific Research

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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:. This position is responsible for providing medical risk analysis for stop loss underwriters on potential ongoing risk for new business cases and in-force renewals. The primary function is to evaluate large claimants and predict ongoing future claim costs relative to the stop loss individual specific level. This risk evaluation is presented to the stop loss underwriter who will use the information to determine how best to offset or mitigate the catastrophic risk, which could impact the overall marketability of the case. Stop-Loss RMS (SLRMS) is a segment of FullscopeRMS that is a new business providing turnkey risk management services to various clients interested in having their own stop loss product.. Preferred skills. Deep knowledge of stop loss product and comfort with medical terminology to identify catastrophic risk.. Strong communication, interpersonal and negotiation skills to interact with senior underwriters, nurses and market managers.. Very strong analytical, problem solving and decision making skills with attention to detail to assess future medical claim risks and costs.. Intermediate skill in Microsoft Excel, Office and strong Internet research skills with ability to simultaneously use multiple systems when reviewing a large claimant.. Effective self-management skills to prioritize daily work and meet deadlines based on the changing needs of senior underwriter/sales/Market Managers.. Qualifications. Bachelor's degree in nursing with 5-8 years clinical experience is preferred.. BA/BS or equivalent with stop loss insurance, medical underwriting or claim experience considered. Responsibilities. Provides individual medical risk analysis on large claimants for proposed stop loss new business and renewal business.. Reviews detailed large claim reports from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports. Analyzes medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs. Researches rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network.. Stays informed of current medical and drug trends and shares information with team members. Projects future costs of care for those claimants who may exceed the Stop loss individual specific level. Determines current treatment and cost of care based on the information received for review.. Presents and documents a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to the senior underwriter who will then present a potential laser/premium load or other creative option to offset the risk if the stop loss deductible level is too low.. Utilizes resources provided to evaluate shock claims which include ICD-10 coding tool, prior medical underwriting reviews from past renewals, shock claims reports and internet research sites and websites that provide averages on claim costs.. Provides training to manual/senior underwriters when applicable.. Reviews any updated medical information that comes in after the initial review to determine if the future risk has changed. Notifies senior underwriter of any updates to the original risk projection.. 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 to learn more.. Sun Life Financial (U.S.) Services Company, Inc. is a federal contractor subject to Executive Order 11246, Section 4212 of the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, and Section 503 of the Rehabilitation Act of 1973, as amended. As such the company is committed to taking positive steps to implement the employment-related aspects of the company's equal employment opportunity policy. It is the company's policy to take affirmative action to employ, advance in employment, and otherwise treat qualified minorities, females, protected veterans, and individuals with disabilities without regard to their race/ethnicity, sex, veteran status, or disability.. Sun Life Financial is in the business of helping our Clients achieve lifetime financial security and live healthier lives. Founded in Can...
Associated topics: biopharmaceutical, diet, immunohematology, medicine, metabolism, microbiological, microbiology, patient, physiologist, toxicologist

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