6 дней назад
Subject Matter Expert (SME) - Clinical Claims Operations
Вакансия из Hirify Global, списка международных tech-компанийДля мэтча и отклика нужен Plus
Мэтч & Сопровод
Для мэтча с этой вакансией нужен Plus
Описание вакансии
Текст:
TL;DR
Subject Matter Expert (SME) - Clinical Claims Operations (Clinical Claims): Supporting disability and clinical claims operations through complex case review, coaching, training, quality governance, and process improvement with an accent on medical documentation, clinical policies, and compliance. Focus on analyzing claims evidence, resolving escalations, calibrating quality standards, and improving workflows in collaboration with operations, training, quality, and client stakeholders.
Location: Taguig, Philippines
Company
provides technology-enabled business process services focused on artificial intelligence, automation, cloud engineering, advanced analytics, and digital transformation.
What you will do
- Serve as the clinical subject matter expert for disability and clinical claims operations.
- Interpret client guidelines, medical policies, standard operating procedures, and clinical documentation.
- Review complex claims, provide recommendations, and support agents, analysts, and leadership teams.
- Conduct case reviews, coaching, refresher training, onboarding support, and knowledge-sharing sessions.
- Partner with Quality Assurance on accuracy, compliance, calibration, audits, and corrective action plans.
- Analyze operational trends and defects and collaborate on workflow and process improvements.
Requirements
- Active and unrestricted US Registered Nurse (USRN) license required.
- Bachelor’s Degree in Nursing (BSN).
- 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.
- At least 1 year of experience as a Subject Matter Expert, Senior Clinical Reviewer, Team Lead, or in an equivalent support role.
- Strong knowledge of medical terminology, disease processes, treatment protocols, clinical documentation, disability management, and insurance claims processes.
- Strong analytical and critical-thinking skills, excellent written and verbal English communication, Microsoft Office proficiency, and willingness to work shifting schedules.
Nice to have
- Experience with disability claims, group benefits, or similar insurance accounts.
- Healthcare BPO or shared-services experience.
- Lean Six Sigma or continuous improvement exposure.
- Experience facilitating training, coaching, quality audits, or process calibration.
- Leadership or project management experience.
Culture & Benefits
- Work with operations, quality, training, workforce, and client stakeholders.
- Participate in continuous improvement, audit, and process governance initiatives.
- Support business requirements through a shifting work schedule.
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