Senior Clinical Claims SME & Operations Coach

Sutherland; Taguig; On-site; PHP 1,339,000 - 2,009,000; Full time

Job summary

Sutherland is seeking a licensed US Registered Nurse (USRN) to join its Clinical Claims Operations as SME, bringing strong clinical claims experience and analytical skills.

You will coach production teams, review cases, apply medical policies, and drive process improvements while ensuring compliance and service excellence. The role requires collaboration with operations leaders, quality teams, trainers, and client stakeholders.

Qualifications

• Active US Registered Nurse license.
• BSN degree required.
• 2–3 years US healthcare experience in disability/clinical claims.
• Minimum 1 year in SME, senior reviewer, team lead, or equivalent role.
• Healthcare BPO/shared services experience preferred.
• Strong written and verbal English communication.

Responsibilities

• Serve as the primary clinical SME for disability and clinical claims operations.
• Interpret and apply client guidelines, medical policies, and SOPs.
• Review complex cases and provide recommendations to teams.
• Support accurate evaluation and documentation of clinical claims.
• Ensure consistency in claims handling and decision-support processes.
• Provide floor support and real-time assistance to agents and analysts.
• Conduct case reviews and knowledge-sharing sessions.
• Identify performance gaps and recommend developmental interventions.
• Collaborate with Operations Managers, Quality Analysts, Trainers, Workforce, and Client Partners.

Skills

USRN license

Analytical thinking

English communication

Willing to shift schedule

Education

BSN

Tools

Excel

Word

PowerPoint

Outlook

Job description

Sutherland is seeking a licensed US Registered Nurse (USRN) to join its Clinical Claims Operations as SME, bringing strong clinical claims experience and analytical skills.

You will coach production teams, review cases, apply medical policies, and drive process improvements while ensuring compliance and service excellence. The role requires collaboration with operations leaders, quality teams, trainers, and client stakeholders.