US Registered Nurse Subject Matter Expert - Clinical Claims Operations

Job Description

Job Summary

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.

This is a dual-role position that requires the incumbent to function both as a Clinical Claims Associate and as a Subject Matter Expert simultaneously. In addition to providing expert guidance, floor support, coaching, and process expertise, the SME is expected to independently perform the same core clinical claims review and case management responsibilities as other team members. The SME will maintain an assigned production workload and is expected to meet established productivity, quality, accuracy, and compliance metrics while providing real-time support to the operations team.

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.
• 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.

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.
• Provide support to associates while actively managing a personal caseload and production responsibilities.
• Serve as a role model by demonstrating effective claims processing techniques, adherence to operational standards, and strong performance outcomes.

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.
• Lead by example by consistently meeting quality and compliance standards in both production and SME-related responsibilities.

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.
• 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
  • Medical Review
  • Insurance Claims Operations
• 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.
• Demonstrated ability to effectively balance individual production responsibilities with Subject Matter Expert support functions.
• Proven experience maintaining performance metrics while providing coaching, floor support, guidance, and operational assistance to peers.
• Strong time management, prioritization, multitasking, and stakeholder management skills in a fast-paced clinical operations environment.

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 

Role Clarification

Important: This is not a dedicated support-only SME position. The selected candidate will be expected to perform the same core clinical claims processing and case review functions as other team members while simultaneously serving as the team's Subject Matter Expert. Success in this role requires balancing production targets, quality expectations, coaching responsibilities, escalation support, and operational excellence.