Subject Matter Expert (SME) - Clinical Claims Operations

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.

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.

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.

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.

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.