Subject Matter Expert (SME) Clinical Claims Operations

The Subject Matter Expert (SME) serves as the clinical and operational resource for the AO Clinical Claims Program. This role provides expertise on clinical claims processes medical documentation review disability management guidelines quality standards and client-specific policies and procedures. The SME supports production teams through coaching training case consultations quality improvement initiatives and process governance to ensure service excellence compliance and operational efficiency.

The ideal candidate is a licensed US Registered Nurse (USRN) with strong clinical claims experience exceptional analytical skills and the ability to collaborate effectively with operations leaders quality teams trainers and client stakeholders.

Key Responsibilities

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.

Team Support and Coaching

• Provide floor support and real-time assistance to agents and analysts.
• Conduct case reviews side-by-side coaching and knowledge-sharing sessions.
• Identify performance gaps and recommend developmental interventions.
• Act as the escalation point for process-related and clinical questions.

Training and Knowledge Management

• Facilitate refresher sessions and uptraining programs.
• Assist Training and Operations teams in creating and updating process documentation.
• Support onboarding activities for new hires.
• Maintain knowledge repositories and ensure process updates are communicated effectively.

Quality and Compliance

• Partner with Quality Assurance teams to drive accuracy and compliance metrics.
• Participate in calibration sessions to ensure consistent interpretation of clinical policies.
• Monitor regulatory and client-driven changes impacting operations.
• Support audit activities and corrective action plans.

Process Improvement

• Identify opportunities to improve workflow efficiency and claim review processes.
• Analyze trends defects and operational challenges.
• Collaborate with stakeholders on continuous improvement initiatives.
• Assist in implementing process enhancements and best practices.

Stakeholder Management

• Work closely with Operations Managers Team Managers Quality Analysts Trainers Workforce and Client Partners.
• Participate in client meetings and discussions when requested.
• Provide insights and recommendations based on operational and clinical findings.

Qualifications :

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Bachelors 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
  • Medical Review
  • Insurance Claims Operations
• At least 1 year experience in a Subject Matter Expert Senior Clinical Reviewer Team Lead or equivalent support role.
• Extensive knowledge of medical terminology disease processes treatment protocols and clinical documentation review.
• Strong understanding of disability management and insurance claims processes.
• Experience working in a healthcare BPO/shared services environment preferred.
• Strong analytical and critical-thinking skills.
• Excellent written and verbal English communication skills.
• Proficient in Microsoft Office applications particularly Excel Word PowerPoint and Outlook.
• Willing to work in a shifting schedule and support business requirements.

Preferred Qualifications

• Experience supporting Disability Claims Group Benefits or similar insurance accounts.
• Lean Six Sigma or Continuous Improvement exposure.
• Experience facilitating training and coaching sessions.
• Background in quality auditing and process calibration.
• Leadership or project management experience.

Additional Information :

Internal Qualifications:

• Must have Annual PDP score of Exceeds Expectations (4) or Outstanding (5)
• Tenure of at least 12 months on the current role
• No Active DA 

Remote Work :

No

Employment Type :

Full-time