Subject Matter Expert (SME) - Clinical Claims Operations

Sutherland; Taguig; Sur place; PHP 1 339 000 - 2 009 000; Plein temps

Résumé du poste

Sutherland is seeking a licensed US Registered Nurse (USRN) to join its Clinical Claims Operations as SME, bringing strong clinical claims experience and analytical skills.

You will coach production teams, review cases, apply medical policies, and drive process improvements while ensuring compliance and service excellence. The role requires collaboration with operations leaders, quality teams, trainers, and client stakeholders.

Qualifications

• Active US Registered Nurse license.
• BSN degree required.
• 2–3 years US healthcare experience in disability/clinical claims.
• Minimum 1 year in SME, senior reviewer, team lead, or equivalent role.
• Healthcare BPO/shared services experience preferred.
• Strong written and verbal English communication.

Responsabilités

• Serve as the primary clinical SME for disability and clinical claims operations.
• Interpret and apply client guidelines, medical policies, and SOPs.
• Review complex cases and provide recommendations to teams.
• Support accurate evaluation and documentation of clinical claims.
• Ensure consistency in claims handling and decision-support processes.
• Provide floor support and real-time assistance to agents and analysts.
• Conduct case reviews and knowledge-sharing sessions.
• Identify performance gaps and recommend developmental interventions.
• Collaborate with Operations Managers, Quality Analysts, Trainers, Workforce, and Client Partners.

Connaissances

USRN license

Analytical thinking

English communication

Willing to shift schedule

Formation

BSN

Outils

Excel

Word

PowerPoint

Outlook

Description du poste

Subject Matter Expert (SME) - Clinical Claims Operations

• Full-time

About Sutherland

Artificial Intelligence. Automation. Cloud engineering. Advanced analytics. For business leaders, these are key factors of success. For us, they’re our core expertise.
We work with iconic brands worldwide. We bring them a unique value proposition through market-leading technology and business process excellence.

We’ve created over 200 unique inventions under several patents across AI and other critical technologies. Leveraging our advanced products and platforms, we drive digital transformation, optimize critical business operations, reinvent experiences, and pioneer new solutions, all provided through a seamless “as a service” model.

For each company, we provide new keys for their businesses, the people they work with, and the customers they serve. We tailor proven and rapid formulas, to fit their unique DNA. We bring together human expertise and artificial intelligence to develop digital chemistry. This unlocks new possibilities, transformative outcomes and enduring relationships.

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.

The ideal candidate is a licensed US Registered Nurse (USRN) with strong clinical claims experience, exceptional analytical skills, and the ability to collaborate effectively with operations leaders, quality teams, trainers, and client stakeholders.

Key Responsibilities

Clinical and Operational Expertise

• 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.

Team Support and Coaching

• Provide floor support and real-time assistance to agents and analysts.
• Conduct case reviews, side-by-side coaching, and knowledge-sharing sessions.
• Identify performance gaps and recommend developmental interventions.
• Act as the escalation point for process-related and clinical questions.

Training and Knowledge Management

• Facilitate refresher sessions and uptraining programs.
• Assist Training and Operations teams in creating and updating process documentation.
• Support onboarding activities for new hires.
• Maintain knowledge repositories and ensure process updates are communicated effectively.

Quality and Compliance

• Partner with Quality Assurance teams to drive accuracy and compliance metrics.
• Participate in calibration sessions to ensure consistent interpretation of clinical policies.
• Monitor regulatory and client-driven changes impacting operations.
• Support audit activities and corrective action plans.

Process Improvement

• Identify opportunities to improve workflow efficiency and claim review processes.
• Analyze trends, defects, and operational challenges.
• Collaborate with stakeholders on continuous improvement initiatives.
• Assist in implementing process enhancements and best practices.

Stakeholder Management

• Work closely with Operations Managers, Team Managers, Quality Analysts, Trainers, Workforce, and Client Partners.
• Participate in client meetings and discussions when requested.
• Provide insights and recommendations based on operational and clinical findings.

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Bachelor's Degree in Nursing (BSN).
• Minimum 2-3 years of US healthcare experience in one or a combination of the following:
  • Disability Claims
  • Clinical Claims Review
  • Utilization Management (UM)
  • Case Management (CM)
  • Workers' Compensation
  • Medical Review
  • Insurance Claims Operations
• At least 1 year experience in a Subject Matter Expert, Senior Clinical Reviewer, Team Lead, or equivalent support role.
• Extensive knowledge of medical terminology, disease processes, treatment protocols, and clinical documentation review.
• Strong understanding of disability management and insurance claims processes.
• Experience working in a healthcare BPO/shared services environment preferred.
• Strong analytical and critical-thinking skills.
• Excellent written and verbal English communication skills.
• Proficient in Microsoft Office applications, particularly Excel, Word, PowerPoint, and Outlook.
• Willing to work in a shifting schedule and support business requirements.

Preferred Qualifications

• Experience supporting Disability Claims, Group Benefits, or similar insurance accounts.
• Lean Six Sigma or Continuous Improvement exposure.
• Experience facilitating training and coaching sessions.
• Background in quality auditing and process calibration.
• Leadership or project management experience.

Internal Qualifications:

• Must have Annual PDP score of Exceeds Expectations (4) or Outstanding (5)
• Tenure of at least 12months on the current role
• No Active DA