USRN Subject Matter Expert (SME) - Clinical Claims

Sutherland; Taguig; On-site; PHP 1,000,000 - 1,600,000; Full time

Job summary

Sutherland is hiring a USRN-licensed Subject Matter Expert (SME) to serve as the clinical and operational resource for the AO Clinical Claims Program. This dual role combines clinical claims review with SME mentorship, coaching, and process governance to ensure quality, compliance, and efficiency.

The candidate will interpret client guidelines, review complex cases, and support production teams through training and real-time floor assistance in a fast-paced healthcare outsourcing environment.

Qualifications

• Active USRN license.
• BSN degree required.
• 2–3 years of US healthcare experience in disability or clinical claims review, utilization management, or case management.
• Strong knowledge of medical terminology and clinical documentation review.
• Excellent written and verbal English communication skills.
• Proficient in Microsoft Excel, Word, PowerPoint, and Outlook.

Responsibilities

• Serve as the primary clinical SME for disability and clinical claims operations.
• Interpret and apply client-specific guidelines, medical policies, and SOPs.
• Review complex cases and provide recommendations to associates and leadership.
• Support accurate evaluation and documentation of claims based on medical evidence.
• Ensure consistency in claims handling and decision-support processes.
• Perform end-to-end clinical claims review, assessment, and documentation activities.

Skills

US healthcare experience

USRN license

BSN

Clinical claims review

Analytical skills

English communication

MS Office

Education

BSN

Tools

MS Office

Job description

About the role

The USRN 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 skills
• Proficient 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