Senior Clinical Claims SME & Operations Leader

Sutherland; Taguig; On-site; PHP 180,000 - 220,000; Full time

Job summary

Sutherland is seeking a US Registered Nurse (USRN) to serve as a Subject Matter Expert for clinical claims operations. The SME will provide expert guidance, floor support, and process governance while managing a personal caseload to meet quality and productivity targets.

The role combines clinical claims review with SME duties, requiring strong collaboration with operations leaders, quality teams, Trainers, and client stakeholders. A BSN and 2–3 years of US healthcare experience are essential.

Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Bachelor's Degree in Nursing (BSN).
• Minimum 2-3 years of US healthcare experience in Disability Claims / Clinical Claims Review / Utilization Management / Case Management.
• Extensive knowledge of medical terminology and clinical documentation review.
• Strong analytical and critical-thinking skills.
• Excellent written and verbal English communication skills.
• Proficient in Microsoft Office applications (Excel, Word, PowerPoint, Outlook).
• Willing to work in a shifting schedule and support business requirements.

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 based on medical evidence.
• Maintain assigned production workload and meet productivity targets.
• Balance SME support with individual case processing and escalation management.

Skills

Analytical skills

Critical thinking

English communication

Time management

Microsoft Office

Education

BSN degree

Tools

Excel

Word

PowerPoint

Outlook

Job description

Sutherland is seeking a US Registered Nurse (USRN) to serve as a Subject Matter Expert for clinical claims operations. The SME will provide expert guidance, floor support, and process governance while managing a personal caseload to meet quality and productivity targets.

The role combines clinical claims review with SME duties, requiring strong collaboration with operations leaders, quality teams, Trainers, and client stakeholders. A BSN and 2–3 years of US healthcare experience are essential.