Subject Matter Expert (SME) - Clinical Claims Operations

Join Sutherland and Make a Meaningful Impact in Healthcare

Are you a passionate US Registered Nurse (USRN) with expertise in disability claims, utilization management, case management, or clinical review Are you ready to elevate your career beyond case handling and become a trusted expert, coach, and leader within a high-performing healthcare operations team

At Sutherland, we're looking for a Clinical Claims Subject Matter Expert (SME) to support our Unum AO Clinical Claims Program. This is a unique opportunity for a clinically driven professional who enjoys solving complex cases, mentoring peers, influencing operational excellence, and helping shape best-in-class claims processes.

In this role, you'll combine your clinical expertise with leadership responsibilities while continuing to manage and review clinical claims. You'll serve as the go-to expert for complex case consultations, process guidance, quality improvement initiatives, and operational support, all while maintaining your own production portfolio.

If you're looking for a role where your expertise is recognized, your voice drives improvements, and your leadership makes a tangible impact, we'd love to hear from you.

Why Join Sutherland

✅ Work with a leading global healthcare services organization

✅ Leverage your USRN expertise in a highly specialized clinical claims environment

✅ Gain visibility with operations leaders and client stakeholders

✅ Develop leadership, coaching, and process improvement skills

✅ Make a direct impact on quality, compliance, and service excellence

✅ Accelerate your career in healthcare operations and insurance services

What You'll Do

Serve as the Clinical Claims Expert

• Act as the primary clinical and operational resource for disability and clinical claims operations.
• Evaluate complex clinical claims and provide expert guidance to associates and leaders.
• Interpret medical records, disability documentation, client policies, and clinical guidelines.
• Ensure accurate, consistent, and evidence-based claims evaluations.
• Support escalation management and resolve complex clinical inquiries.

Manage Your Own Clinical Claims Portfolio

• Perform end-to-end clinical claims reviews and assessments.
• Maintain an assigned production workload while meeting performance expectations.
• Achieve quality, productivity, accuracy, and compliance targets.
• Demonstrate best practices in claims review and clinical decision-making.

Coach, Mentor, and Support Team Performance

• Provide real-time floor support and case consultation.
• Conduct coaching sessions, case reviews, and knowledge-sharing activities.
• Help identify performance gaps and contribute to employee development.
• Serve as a role model for operational excellence and clinical accuracy.

Drive Quality and Continuous Improvement

• Partner with Quality and Operations teams to improve claims accuracy and compliance.
• Participate in calibrations, audits, and process governance activities.
• Analyze trends, identify opportunities, and recommend process enhancements.
• Support implementation of best practices and operational improvements.

Collaborate with Key Stakeholders

• Work closely with Operations Managers, Team Managers, Quality Analysts, Trainers, Workforce teams, and Client Partners.
• Participate in client discussions and provide clinical insights when needed.
• Contribute to strategic initiatives that improve performance and service delivery.

What We're Looking For

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) License
• Bachelor's Degree in Nursing (BSN)
• At least 2-3 years of US healthcare experience in one or more of the following areas:
• Disability Claims
• Clinical Claims Review
• Utilization Management (UM)
• Case Management (CM)
• Workers Compensation
• Medical Review
• Insurance Claims Operations
• Strong understanding of disability management and insurance claims processes
• Extensive clinical knowledge, including medical terminology, disease processes, treatment protocols, and medical documentation review
• Excellent analytical and critical-thinking skills
• Strong written and verbal English communication skills
• Proficiency in Microsoft Office applications
• Ability to work in a fast-paced, performance-driven environment
• Willingness to work on shifting schedules

Preferred Qualifications

• Experience supporting Disability Claims or Group Benefits accounts
• Background in healthcare BPO/shared services operations
• Experience facilitating training, coaching, or mentoring activities
• Quality auditing and calibration experience
• Continuous Improvement or Lean Six Sigma exposure
• Leadership, project management, or team support experience

Who Will Thrive in This Role

This opportunity is ideal for a high-performing USRN who enjoys both clinical case review and leadership responsibilities. The successful candidate is someone who can confidently manage a personal workload while serving as a trusted advisor, coach, and escalation resource for the broader team.

You'll thrive here if you enjoy:

• Solving complex clinical cases
• Influencing outcomes through expertise
• Coaching and developing colleagues
• Driving quality and operational excellence
• Building a long-term career in healthcare operations leadership

Important Note:

This is a true SME role with hands-on clinical claims responsibilities. You will actively manage your own claims portfolio while providing coaching, floor support, case consultations, and operational guidance to the team. Success in this role requires balancing production performance, quality standards, stakeholder support, and SME responsibilities.

Ready to bring your clinical expertise to a role where you can lead, influence, and make an impact Apply today and grow your career with Sutherland.