Subject Matter Expert - USRN

Job Summary

The SME serves as the clinical and operational expert for the Clinical Claims Program, providing guidance on claims processes, medical documentation review, disability management, quality standards, and client-specific procedures. This is a dual-role position requiring the incumbent to manage an individual clinical claims workload while simultaneously supporting the team through coaching, case consultations, floor support, training, and process improvement initiatives.

The role is ideal for a licensed US Registered Nurse (USRN) with strong clinical claims experience, excellent analytical skills, and the ability to collaborate effectively with operations, quality, training, and client stakeholders.

Key Responsibilities

• Perform end-to-end clinical claims review, assessment, and documentation while meeting productivity, quality, accuracy, and compliance targets.
• Serve as the primary subject matter expert for complex clinical and operational inquiries.
• Provide floor support, coaching, case reviews, and real-time guidance to team members.
• Support onboarding, uptraining, and knowledge management initiatives.
• Partner with Quality, Operations, and Training teams to drive compliance, consistency, and service excellence.
• Identify process improvement opportunities and support implementation of best practices.
• Collaborate with internal stakeholders and client partners to address operational and clinical concerns.

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 Disability Claims, Clinical Claims Review, Utilization Management, Case Management, Workers' Compensation, Medical Review, or Insurance Claims Operations.
• Strong knowledge of medical terminology, clinical documentation review, disability management, and insurance claims processes.
• Excellent analytical, communication, coaching, and stakeholder management skills.
• Proficiency in Microsoft Office applications.
• Ability to balance production responsibilities with SME support functions in a fast-paced environment.
• Willingness to work flexible or shifting schedules.

Preferred Qualifications

• Experience supporting Disability Claims, Group Benefits, or related insurance programs.
• Background in training, quality auditing, and process calibration.
• Lean Six Sigma, continuous improvement, leadership, or project management experience.

Note: This is not a dedicated support role. Successful candidates will be expected to maintain an individual production workload while providing SME support, coaching, escalation management, and operational guidance to the team.

Internal Qualifications:

• 12 months tenure in the recent role
• No Active DA for the past 6 months
• Recent annual PDP rating of 4 (Exceeds Expectations) or 5 (Outstanding)