Subject Matter Expert (SME) - Clinical Claims Operations

Sutherland
Philippines
Workplace: OnsiteFull timeFunction: Insurance & ActuarialExperience: 2-3 yearsEducation: bachelorsSkills: ["Analytical skills","Critical thinking","Time management","Stakeholder management","Communication"]

Serve as the primary clinical and operational subject matter expert for disability and clinical claims. Interpret client guidelines and medical policies, review complex cases, and independently handle the same end-to-end clinical claims and case management work as other team members. Provide floor support, real-time coaching, escalation guidance, refresher training, and support onboarding. Drive quality and compliance through calibration, audits, and continuous improvement initiatives while maintaining productivity and accuracy metrics.

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FursaFursa
Sutherland
Sutherland
3 days ago

Subject Matter Expert (SME) - Clinical Claims Operations

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Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 48 minutes agoStatus: Live
Reposted: similar role first listed 6 days ago

Job Summary

Serve as the primary clinical and operational subject matter expert for disability and clinical claims. Interpret client guidelines and medical policies, review complex cases, and independently handle the same end-to-end clinical claims and case management work as other team members. Provide floor support, real-time coaching, escalation guidance, refresher training, and support onboarding. Drive quality and compliance through calibration, audits, and continuous improvement initiatives while maintaining productivity and accuracy metrics.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Insurance & Actuarial

Key Responsibilities

  • •Act as the primary SME for disability and clinical claims operations, interpreting client guidelines, medical policies, and SOPs.
  • •Review complex cases and provide recommendations to associates and leadership while performing end-to-end clinical claims review, assessment, and documentation.
  • •Provide floor support and real-time assistance, including case reviews, side-by-side coaching, knowledge-sharing, and serving as an escalation point.
  • •Facilitate refresher sessions and uptraining, support onboarding, and assist with creating and updating process documentation and knowledge repositories.
  • •Partner with Quality Assurance teams, participate in calibration, monitor changes, support audits/corrective actions, and identify process improvement opportunities.

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.
  • •Extensive knowledge of medical terminology, disease processes, treatment protocols, and clinical documentation review.
  • •Proficient in Microsoft Office (Excel, Word, PowerPoint, Outlook) and able to meet productivity, quality, accuracy, and compliance metrics while supporting SME responsibilities.
Experience:2-3 yearsHealthcareInsuranceDisability claims
Education:Bachelor's in Nursing
Skills:Analytical skillsCritical thinkingTime managementStakeholder managementCommunication
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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