Clinical Claims Expert & SME

Sutherland; Taguig; Hybrid; PHP 900,000 - 1,300,000; Full time

Job summary

Sutherland is seeking a highly qualified Subject Matter Expert (SME) for its AO Clinical Claims Program. The role combines clinical claims review with expert guidance, coaching, and process governance to ensure service excellence and compliance.

Ideal candidates hold an active USRN license, a BSN, and 2–3 years of US healthcare experience in disability or clinical claims, with strong English communication skills and proficiency in MS Office.

Qualifications

• Active US Registered Nurse (USRN) license.
• Bachelor's Degree in Nursing (BSN).
• Minimum 2–3 years of US healthcare experience in disability/clinical claims or related operations.
• Strong knowledge of medical terminology, disease processes, and clinical documentation review.
• Excellent written and verbal English communication; proficient in MS Office.

Responsibilities

• Serve as the primary clinical SME for disability and clinical claims operations.
• Interpret and apply client-specific guidelines and procedures.
• Review complex cases and provide recommendations to associates and leadership.
• Support accurate evaluation and documentation of clinical claims based on medical evidence.
• Ensure consistency in claims handling and decision-support processes.
• Perform end-to-end clinical claims review, assessment, and documentation.
• Maintain a production workload and meet productivity and quality targets.
• Provide floor support and real-time assistance to agents and analysts.
• Conduct case reviews, coaching, and knowledge-sharing sessions.
• Facilitate refresher sessions and uptraining programs.

Skills

US healthcare

Clinical claims

Disability claims

Utilization management

Case management

Medical terminology

MS Office

Excel

Time management

Stakeholder management

English communication

Education

BSN (Bachelor of Science in Nursing)

Tools

Microsoft Office

Job description

Sutherland is seeking a highly qualified Subject Matter Expert (SME) for its AO Clinical Claims Program. The role combines clinical claims review with expert guidance, coaching, and process governance to ensure service excellence and compliance.

Ideal candidates hold an active USRN license, a BSN, and 2–3 years of US healthcare experience in disability or clinical claims, with strong English communication skills and proficiency in MS Office.