Clinical Claims & Appeals Reviewer (RN)

Sutherland; Taguig; Hybrid; PHP 600,000 - 900,000; Full time

Job summary

Sutherland in the Philippines seeks a qualified nurse to review medical information and claims with clinical judgment and evidence-based rationale. The role requires an active USRN license, 1 year in Clinical Claims/Denials & Appeals, and 1 year in a BPO environment.

Strong communication in English and the ability to engage with stakeholders is essential, with a focus on accuracy, productivity, and compliance in a fast-paced setting.

Qualifications

• Active US Registered Nurse (USRN) license required.
• 1 year of Clinical Claims / Denials & Appeals experience.
• 1 year of experience in BPO.
• Behavioral Health experience is preferred.
• Strong clinical assessment and medical information analysis skills.
• Demonstrated ability to apply medical knowledge to complex cases with evidence-based conclusions.
• Advanced critical thinking, analytical reasoning, clinical judgment, and decision-making capabilities.
• Strong interpersonal and stakeholder management skills and ability to handle sensitive conversations.
• Excellent written and verbal English communication skills.

Responsibilities

• Review and assess medical information and claim files using clinical knowledge and evidence-based practices.
• Analyze and synthesize complex medical information to develop balanced, accurate conclusions.
• Apply advanced critical thinking, analytical reasoning, and clinical judgment when evaluating cases.
• Engage with internal and external stakeholders in high-impact conversations.
• Obtain, clarify, and validate medical information from stakeholders.
• Provide coaching to non-medical staff on medical concepts and considerations.
• Maintain productivity while meeting quality, accuracy, and volume standards.
• Stay informed of new developments and best practices in the medical field.

Skills

USRN license

Clinical Claims

BPO experience

English communication

Job description

Sutherland in the Philippines seeks a qualified nurse to review medical information and claims with clinical judgment and evidence-based rationale. The role requires an active USRN license, 1 year in Clinical Claims/Denials & Appeals, and 1 year in a BPO environment.

Strong communication in English and the ability to engage with stakeholders is essential, with a focus on accuracy, productivity, and compliance in a fast-paced setting.