Senior Clinical Claims SME - RN Lead

Sutherland; Pateros; On-site; PHP 670,000 - 1,004,000; Full time

Job summary

Sutherland in Manila is seeking a licensed US Registered Nurse (USRN) Subject Matter Expert to support the AO Clinical Claims Program. The SME provides clinical claims expertise, reviews documentation, and ensures quality and compliance for efficient operations.

The role requires 2–3 years of US healthcare experience, strong analytical abilities, and collaboration with operations leaders, quality teams, trainers, and client stakeholders in a healthcare BPO setting.

Qualifications

• Active US Registered Nurse license (unrestricted).
• BSN required with US healthcare experience 2–3 years.
• Experience in disability/clinical claims and utilization management.
• Experience in healthcare BPO/shared services preferred.
• Strong English communication and analytical skills.

Responsibilities

• Serve as the clinical SME for disability and clinical claims operations.
• Interpret client guidelines, policies and SOPs for claims review.
• Review complex cases and provide recommendations to teams.
• Support measurement and governance of claims processes for quality.
• Coach and support agents with real-time floor guidance.

Skills

Analytical thinking

English communication

Clinical claims analysis

Disability claims knowledge

Quality assurance

Education

Bachelor's Degree in Nursing (BSN)

Tools

Excel

Word

PowerPoint

Outlook

Job description

Sutherland in Manila is seeking a licensed US Registered Nurse (USRN) Subject Matter Expert to support the AO Clinical Claims Program. The SME provides clinical claims expertise, reviews documentation, and ensures quality and compliance for efficient operations.

The role requires 2–3 years of US healthcare experience, strong analytical abilities, and collaboration with operations leaders, quality teams, trainers, and client stakeholders in a healthcare BPO setting.