Subject Matter Expert (SME) - Clinical Claims Operations

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Skills you'll use

What you'll do

• Clinical and Operational Expertise
• 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.
• Balance individual case processing responsibilities with SME support, coaching, and escalation management activities.
• Demonstrate best practices in claims handling, clinical documentation review, and decision-making while serving as a role model for the team.

Who can apply

• 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 one or a combination of the following: • Disability Claims
• Clinical Claims Review
• Utilization Management (UM)
• Case Management (CM)
• Workers' Compensation
• Insurance Claims Operations
• Extensive knowledge of medical terminology, disease processes, treatment protocols, and clinical documentation review.

About Sutherland

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