USRN Subject Matter Expert (SME) – Clinical Claims Operations

E-Solutions; Taguig; On-site; PHP 893,000 - 1,339,000; Full time

Job summary

E-Solutions is seeking a Clinical Claims SME with active US RN licensure to guide and support their US healthcare claims operations in Taguig. The role combines production work with SME coaching, documentation review, and escalation support.

The ideal candidate has a BSN and 2–3 years of US healthcare experience in disability, clinical claims review, case management, or workers’ compensation, and is willing to work onsite with eventual transition to work-from-home as the program stabilizes.

Qualifications

• Active and unrestricted US Registered Nurse license
• BSN degree required
• 2–3 years US healthcare experience in claims/clinical areas

Responsibilities

• Provide SME clinical guidance to Clinical Claims Operations team
• Review clinical documentation and claims-related information for accuracy and compliance
• Support escalations and complex claims issues with guidance
• Coach team members and share clinical knowledge
• Monitor performance and identify process improvement opportunities
• Collaborate with stakeholders to ensure efficient claims processing
• Balance production with SME support in a fast-paced environment

Skills

USRN license

BSN

Clinical claims

Coaching

Stakeholder management

Microsoft Office

Education

BSN

Tools

Microsoft Office

Job description

In this role, you will leverage your clinical expertise and US healthcare experience to provide subject matter guidance, support claims operations, ensure quality and accuracy in clinical reviews, and assist in maintaining operational excellence.

The ideal candidate has a strong background in clinical claims, disability management, utilization management, or related US healthcare operations, with the ability to balance production responsibilities and SME support functions.

Key Responsibilities

• Provide subject matter expertise and clinical guidance to the Clinical Claims Operations team.
• Support the review and interpretation of clinical documentation, medical records, and claims-related information.
• Ensure accuracy, consistency, and compliance with established clinical review guidelines and insurance claims processes.
• Assist in resolving complex clinical claims-related issues and provide guidance on escalations.
• Support team members through coaching, knowledge sharing, and clarification of clinical processes.
• Monitor operational performance and identify opportunities for process improvement.
• Collaborate with stakeholders to ensure efficient and effective claims processing.
• Balance individual production responsibilities with SME support functions in a fast-paced environment.

Qualifications

• Must possess an active and unrestricted US Registered Nurse (USRN) license.
• Bachelor's Degree in Nursing (BSN) is required.
• Minimum of 2–3 years of US healthcare experience in any of the following areas:

Disability Claims

Clinical Claims Review

Case Management

Workers' Compensation

Medical Review

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.
• Proficient in Microsoft Office applications.
• Ability to manage production responsibilities while providing SME support.
• Willingness to work flexible or shifting schedules.
• Willingness to work onsite in Taguig, with the opportunity to transition to WAH once the program stabilizes.