USRN Subject Matter Expert (SME) - Clinical Claims Operations | 200k SOB
Core
US Registered Nurse performing end-to-end clinical claims review, assessment, and documentation while simultaneously providing expert guidance, coaching, and process governance to operations teams.
Role type
Senior IC clinical claims specialist (dual production/SME)
Builds
Disability and clinical claims decisions, medical documentation reviews, and operational process improvements
Domain
US Healthcare Insurance / Disability Claims
Required skills
US Registered Nurse (USRN) license, clinical claims review, medical documentation analysis, disability management guidelines, utilization management, case management, workers' compensation, medical review, insurance claims operations, Microsoft Office (Excel, Word, PowerPoint, Outlook)
Preferred skills
Healthcare BPO/shared services environment experience, Lean Six Sigma, training facilitation, quality auditing, process calibration, leadership or project management
Technologies
Microsoft Office Suite (Excel, Word, PowerPoint, Outlook)
Responsibilities
Perform end-to-end clinical claims review and case management to meet productivity and quality metrics, interpret client-specific guidelines and medical policies, provide real-time floor support and coaching to associates, conduct case reviews and calibration sessions, facilitate training and uptraining programs, identify process improvement opportunities and implement best practices, partner with Quality Assurance teams to drive compliance metrics
Seniority
Senior, hands-on IC with production responsibilities