Subject Matter Expert - USRN

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

Company Description:

Artificial Intelligence. Automation. Cloud Engineering. Advanced Analytics.
For Enterprises, these are key factors of success. For us, they're our core expertise.
We work with global iconic brands. We bring them a unique value proposition through market-leading technologies and business process excellence. At the heart of it all is Digital Engineering - the foundation that powers rapid innovation and scalable business transformation.
We've created 363 unique and independent inventions, 250 of which are AI-based and rolled up under several patent grants in critical technologies. Leveraging our advanced products and platforms, we drive digital transformation at scale, 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. With proven strategies and agile execution, we don't just enable change - we engineer digital outcomes.
Sutherland
Digital Outcomes.

Job Description:

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.

The role is ideal for a licensed US Registered Nurse (USRN) with strong clinical claims experience, excellent analytical skills, and the ability to collaborate effectively with operations, quality, training, and client stakeholders.

Key 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.

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 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.

Preferred Qualifications

• Experience supporting Disability Claims, Group Benefits, or related insurance programs.
• Background in training, quality auditing, and process calibration.
• Lean Six Sigma, continuous improvement, leadership, or project management experience.

Note: This is not a dedicated support role. Successful candidates will be expected to maintain an individual production workload while providing SME support, coaching, escalation management, and operational guidance to the team.

Additional Information:

Internal Qualifications:

• 12 months tenure in the recent role
• No Active DA for the past 6 months
• Recent annual PDP rating of 4 (Exceeds Expectations) or 5 (Outstanding)