Subject Matter Expert (SME) - Clinical Claims

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

About the role

The Subject Matter Expert (SME) serves as the clinical and operational resource for the AO Clinical Claims Program. This role provides expertise on clinical claims processes, medical documentation review, disability management guidelines, quality standards, and client-specific policies and procedures. The SME supports production teams through coaching, training, case consultations, quality improvement initiatives, and process governance to ensure service excellence, compliance, and operational efficiency. This is a dual-role position that requires the incumbent to function both as a Clinical Claims Associate and as a Subject Matter Expert simultaneously. In addition to providing expert guidance, floor support, coaching, and process expertise, the SME is expected to independently perform the same core clinical claims review and case management responsibilities as other team members.

Key responsibilities

• Serve as the primary clinical subject matter expert for disability and clinical claims operations
• Interpret and apply client-specific guidelines, medical policies, and standard operating procedures
• Review complex cases and provide recommendations to associates and leadership teams
• Support accurate evaluation and documentation of clinical claims based on medical evidence and established protocols
• Ensure consistency in claims handling and decision-support processes
• Perform end-to-end clinical claims review, assessment, and documentation activities consistent with the responsibilities of a Clinical Claims Associate/Analyst
• Maintain an assigned production workload and achieve established productivity, quality, accuracy, and compliance targets
• Provide floor support and real-time assistance to agents and analysts
• Conduct case reviews, side-by-side coaching, and knowledge-sharing sessions
• Facilitate refresher sessions and uptraining programs

About you

• Active and unrestricted US Registered Nurse (USRN) license
• Bachelor's Degree in Nursing (BSN)
• Minimum 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
• Extensive knowledge of medical terminology, disease processes, treatment protocols, and clinical documentation review
• Strong understanding of disability management and insurance claims processes
• Strong analytical and critical-thinking skills
• Excellent written and verbal English communication skillsProficient in Microsoft Office applications, particularly Excel, Word, PowerPoint, and Outlook
• Demonstrated ability to effectively balance individual production responsibilities with Subject Matter Expert support functions
• Strong time management, prioritization, multitasking, and stakeholder management skills in a fast-paced clinical operations environment