Clinical Claims SME (RN) — Coaching & Process Excellence

Sutherland Global; Taguig; Hybrid; PHP 600,000 - 900,000; Full time

Job summary

The SME serves as the clinical and operational expert for the Clinical Claims Program, providing guidance on claims processes, medical documentation review, disability management, quality standards, and client-specific procedures.

This is a dual-role position requiring the incumbent to manage an individual clinical claims workload while simultaneously supporting the team through coaching, case consultations, floor support, training, and process improvement initiatives.

Qualifications

• Active and unrestricted US Registered Nurse license.
• Bachelor's Degree in Nursing (BSN).
• 2-3 years of US healthcare experience in Disability Claims, Clinical Claims Review, Utilization Management, Case Management, Workers' Compensation, Medical Review, or Insurance Claims Operations.
• Strong knowledge of medical terminology, clinical documentation review, disability management, and insurance claims processes.
• Excellent analytical, communication, coaching, and stakeholder management skills.
• Proficiency in Microsoft Office applications.
• Ability to balance production responsibilities with SME support functions in a fast-paced environment.
• Willingness to work flexible or shifting schedules.

Responsibilities

• Perform end-to-end clinical claims review, assessment, and documentation while meeting productivity, quality, accuracy, and compliance targets.
• Serve as the primary subject matter expert for complex clinical and operational inquiries.
• Provide floor support, coaching, case reviews, and real-time guidance to team members.
• Support onboarding, uptraining, and knowledge management initiatives.
• Partner with Quality, Operations, and Training teams to drive compliance, consistency, and service excellence.
• Identify process improvement opportunities and support implementation of best practices.
• Collaborate with internal stakeholders and client partners to address operational and clinical concerns.

Skills

Clinical claims review

Analytical mindset

Stakeholder management

Coaching

Process improvement

Education

BSN (Bachelor of Science in Nursing)

Tools

Microsoft Office

Job description

The SME serves as the clinical and operational expert for the Clinical Claims Program, providing guidance on claims processes, medical documentation review, disability management, quality standards, and client-specific procedures.

This is a dual-role position requiring the incumbent to manage an individual clinical claims workload while simultaneously supporting the team through coaching, case consultations, floor support, training, and process improvement initiatives.