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SutherlandUSRN Subject Matter Expert (SME) - Clinical Claims Operations | 200k SOB
Sutherland is hiring a USRN Subject Matter Expert (SME) - Clinical Claims Operations for the AO Clinical Claims Program. This position operates on-site. The role functions…
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About This Role
Sutherland is hiring a USRN Subject Matter Expert (SME) - Clinical Claims Operations for the AO Clinical Claims Program. This position operates on-site. The role functions as a hybrid capacity, requiring the individual to handle an independent production workload of clinical claims reviews and case management while concurrently offering real-time floor support, coaching, escalations management, and process guidance to the team. The SME will partner closely with quality assurance, training,…
Job Description
Sutherland is hiring a USRN Subject Matter Expert (SME) - Clinical Claims Operations for the AO Clinical Claims Program. This position operates on-site. The role functions as a hybrid capacity, requiring the individual to handle an independent production workload of clinical claims reviews and case management while concurrently offering real-time floor support, coaching, escalations management, and process guidance to the team. The SME will partner closely with quality assurance, training, and operations stakeholders to maintain high service levels, drive process improvements, and ensure adherence to client-specific medical policies. This opportunity suits a licensed nurse with robust clinical claims background who can balance personal productivity goals with team mentorship.
Responsibilities
- Function simultaneously as a Clinical Claims Associate and a Subject Matter Expert by maintaining an assigned case review workload alongside support duties
- Interpret and apply client-specific guidelines, standard operating procedures, and medical policies to complex claims
- Deliver real-time assistance, floor support, and side-by-side coaching to agents and analysts
- Act as the primary escalation point for clinical and process-related questions
- Partner with Quality Assurance teams to monitor metrics, participate in calibration sessions, and support audits
- Facilitate refresher training, uptraining programs, and assist with onboarding new hires
- Identify workflow inefficiencies, analyze operational trends, and contribute to continuous improvement initiatives
Requirements
- Active and unrestricted US Registered Nurse license
- Bachelor of Science in Nursing degree
- Minimum of two to three years of US healthcare experience in disability claims, clinical claims review, utilization management, case management, workers' compensation, medical review, or insurance claims operations
- Comprehensive knowledge of medical terminology, disease processes, treatment protocols, and clinical documentation review
- Strong understanding of insurance claims and disability management processes
- Proficiency in Microsoft Office applications including Excel, Word, PowerPoint, and Outlook
- Availability to work in a shifting schedule
Qualifications
- Experience working in a healthcare business process outsourcing or shared services environment
- Prior experience supporting group benefits or disability claims accounts
- Exposure to Lean Six Sigma or continuous improvement methods
- Background in facilitating coaching and training sessions
- Previous experience in quality auditing and process calibration
- Prior leadership or project management experience
Core Skills
Benefits
- 200k sign-on bonus
Frequently Asked Questions
Answers are based only on the employer’s listing; where it doesn’t say, neither do we.
What is the remote work policy for this role?
The source posting states that this position is on-site.
What are the primary responsibilities of this position?
The incumbent must independently process a personal caseload of clinical claims and case reviews while simultaneously providing real-time floor support, coaching, training assistance, and escalation management to peers.
What licensure and education are required?
Candidates must hold an active and unrestricted US Registered Nurse license and possess a Bachelor of Science in Nursing degree.
Sample Interview Questions
AI-generated questions tailored to this specific role — a preview of the full practice set.