Subject Matter Expert (SME) - USRN - Taguig

About the role

Sutherland is hiring a Subject Matter Expert (SME) for its AO Clinical Claims Program in Taguig. The role is dual: the incumbent acts as a Clinical Claims Associate performing the same core review and case management work as other team members, while also providing clinical expertise, coaching, training and quality support. The ideal candidate is a licensed US Registered Nurse (USRN) with strong clinical claims experience.

Key responsibilities

• Review complex clinical claims and provide recommendations to associates and leadership, ensuring accurate evaluation and documentation based on medical evidence.
• Maintain an assigned production workload and meet productivity, quality, accuracy and compliance targets.
• Provide floor support, case reviews, side-by-side coaching and knowledge sharing, and act as escalation point for process and clinical questions.
• Facilitate refresher sessions, help create and update process documentation, support onboarding, and maintain knowledge repositories.
• Partner with Quality Assurance teams, take part in calibration sessions, monitor regulatory changes, support audits and corrective actions, and identify process improvements.
• Work with Operations Managers, Team Managers, Quality Analysts, Trainers, Workforce and Client Partners, including in client meetings when requested.

Required profile

• Active and unrestricted US Registered Nurse (USRN) license and Bachelor's degree in Nursing (BSN).
• At least 2-3 years of US healthcare experience in disability claims, clinical claims review, utilization management, case management, workers' compensation, medical review, insurance claims operations or a combination.
• Preferred: experience in a healthcare BPO/shared services environment, disability claims or group benefits accounts, Lean Six Sigma or continuous improvement exposure, training/coaching facilitation, quality auditing/calibration background, and leadership or project management experience.
• Internal requirement: annual PDP score of Exceeds Expectations (4) or Outstanding (5), at least 12 months tenure on the current role, and no active disciplinary action.

Required skills

• Extensive knowledge of medical terminology, disease processes, treatment protocols and clinical documentation review.
• Strong analytical and critical thinking skills, excellent written and verbal English, and proficiency in Microsoft Office (Excel, Word, PowerPoint, Outlook).
• Ability to balance production responsibilities with coaching and support roles, and to work in a shifting schedule.