Subject Matter Expert (SME) - Clinical Claims Operations

Sutherland
Philippines
Workplace: OnsiteFull timeFunction: Insurance & ActuarialExperience: 2-3 yearsEducation: bachelorsSkills: ["Analytical skills","Critical thinking","Collaboration","Written communication","Verbal communication"]

Serve as the clinical and operational subject matter expert for disability and clinical claims operations. Interpret client-specific guidelines and medical policies, review complex cases, and ensure consistent decision-support. Provide floor support, escalation, and side-by-side coaching to associates and analysts. Facilitate refresher training and keep process documentation current. Partner with QA on accuracy/compliance, support calibration and audits, and drive continuous improvement initiatives.

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FursaFursa
Sutherland
Sutherland
1 day ago

Subject Matter Expert (SME) - Clinical Claims Operations

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Source: Company careers pageValidated by: Fursa AI
Last checked: 13 hours agoStatus: Live

Job Summary

Serve as the clinical and operational subject matter expert for disability and clinical claims operations. Interpret client-specific guidelines and medical policies, review complex cases, and ensure consistent decision-support. Provide floor support, escalation, and side-by-side coaching to associates and analysts. Facilitate refresher training and keep process documentation current. Partner with QA on accuracy/compliance, support calibration and audits, and drive continuous improvement initiatives.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Insurance & Actuarial
Seniority: Mid level

Key Responsibilities

  • •Act as the primary clinical subject matter expert for disability and clinical claims operations, interpreting client guidelines, medical policies, and SOPs.
  • •Review complex cases and recommend decisions based on medical evidence and established protocols; ensure consistency in claims handling and decision support.
  • •Provide floor support, real-time assistance, case reviews, side-by-side coaching, and serve as the escalation point for clinical/process questions.
  • •Facilitate refresher sessions and uptraining, assist with process documentation updates, support onboarding, and maintain knowledge repositories.
  • •Partner with Quality Assurance for accuracy/compliance, participate in calibration and audits, support corrective actions, and identify opportunities for workflow and process improvements.

Key Requirements

  • •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.
  • •At least 1 year experience in a Subject Matter Expert, Senior Clinical Reviewer, Team Lead, or equivalent support role.
  • •Extensive medical terminology and clinical documentation review knowledge, with strong analytical skills and excellent written/verbal English communication.
Experience:2-3 yearsHealthcareInsuranceDisability claims
Education:Bachelor's in Nursing
Skills:Analytical skillsCritical thinkingCollaborationWritten communicationVerbal communication
Licenses:US Registered Nurse (USRN)
Languages:English
Tech Stack:Microsoft OfficeExcelWordPowerPointOutlook

Company Brief

Sutherland
Global digital transformation and business process services firm offering AI, automation, cloud engineering, analytics and customer experience solutions to enterprises across industries.
Industry: Professional Services
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Established Company
Funding: Private Equity Backed
Headquarters: Pittsford (Rochester), NY, United States
Founded: 1986
Glassdoor
Glassdoor: 3.5
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