USRN Clinical Reviewer | Utilization Management

Sutherland; Taguig; On-site; PHP 600,000 - 900,000; Full time

Benefits offered by this job

Competitive compensation

Comprehensive benefits

Job summary

Sutherland is seeking highly analytical US Registered Nurses (USRNs) to join our healthcare team in Manila. Review complex cases, evaluate supporting documentation, and provide evidence-based recommendations for informed healthcare decisions.

Ideal candidates will have UR/UM experience, strong clinical judgment, and excellent English communication skills. This on-site role offers competitive compensation and comprehensive benefits in a fast-paced environment.

Qualifications

• Active and unrestricted USRN license.
• Minimum 1 year clinical nursing experience in a hospital, healthcare, or related setting.
• Experience in UR/UM/Clinical Review/Case Management/Appeals/Medical Claims Review.
• Strong clinical assessment and medical record review skills.
• Advanced critical thinking, analytical reasoning, and decision-making capabilities.
• Excellent written and verbal English communication skills.
• Ability to engage effectively with physicians, healthcare providers, and cross-functional stakeholders.
• Strong organizational skills with ability to manage multiple priorities and meet targets.

Responsibilities

• Review and evaluate medical records, clinical documentation, and claim-related information to support accurate determinations.
• Analyze complex clinical cases and synthesize medical information into clear, balanced, and well-supported recommendations.
• Apply advanced nursing knowledge, clinical judgment, and critical thinking to assess conditions, treatments, and outcomes.
• Collaborate with internal stakeholders, healthcare providers, and attending physicians to gather, clarify, and validate clinical information.
• Conduct professional discussions regarding complex clinical matters with empathy and professionalism.
• Identify gaps or additional information needed to support clinical decision-making.
• Serve as a trusted clinical resource by guiding non-medical teams on medical terminology and treatment plans.
• Ensure compliance with clinical guidelines, regulatory requirements, and quality standards.
• Meet productivity, quality, accuracy, and SLA expectations in a fast-paced environment.
• Stay current with healthcare trends and nursing standards.

Skills

USRN license

Clinical nursing experience

Analytical reasoning

Decision-making

English communication

Stakeholder engagement

Organizational skills

Job description

Sutherland is seeking highly analytical and detail-oriented US Registered Nurses (USRNs) to join our growing healthcare team. In this role, you will leverage your clinical expertise to review complex medical cases, evaluate supporting documentation, and provide evidence-based recommendations that help drive informed healthcare and disability-related decisions.

This opportunity is ideal for nurses who enjoy critical thinking, medical record analysis, stakeholder collaboration, and applying clinical judgment beyond direct patient care. You will work alongside physicians, healthcare professionals, and business partners while making a meaningful impact on case outcomes and customer experiences.

What You'll Do

• Review and evaluate medical records, clinical documentation, and claim-related information to support accurate and evidence-based determinations.
• Analyze complex clinical cases and synthesize medical information into clear, balanced, and well-supported recommendations.
• Apply advanced nursing knowledge, clinical judgment, and critical thinking skills to assess medical conditions, treatments, functional limitations, and outcomes.
• Collaborate with internal stakeholders, healthcare providers, and attending physicians to gather, clarify, and validate clinical information.
• Conduct professional discussions regarding complex or sensitive clinical matters while maintaining a high level of empathy and professionalism.
• Identify gaps, inconsistencies, or additional information needed to support clinical decision-making.
• Serve as a trusted clinical resource by providing guidance and coaching to non-medical teams regarding medical terminology, diagnoses, treatment plans, and clinical concepts.
• Ensure compliance with established clinical guidelines, regulatory requirements, and quality standards.
• Consistently meet productivity, quality, accuracy, and service-level expectations in a fast-paced environment.
• Stay current with emerging healthcare trends, nursing standards, and evidence-based clinical practices.

What We're Looking For

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) License.
• Minimum of 1 year clinical nursing experience in a hospital, healthcare, or related clinical setting.
• Experience in Utilization Review (UR), Utilization Management (UM), Clinical Review, Case Management, Appeals, or Medical Claims Review.
• Strong clinical assessment and medical record review skills.
• Advanced critical thinking, analytical reasoning, and decision-making capabilities.
• Excellent written and verbal English communication skills.
• Ability to effectively engage with physicians, healthcare providers, and cross-functional stakeholders.
• Strong organizational skills with the ability to manage multiple priorities and meet performance targets.

Preferred Qualifications

• Experience reviewing disability, absence management, life insurance, workers' compensation, or healthcare-related claims.
• Exposure to evidence-based clinical guidelines and medical necessity reviews.
• Experience supporting US healthcare programs or insurance operations.

Why Join Sutherland?

Competitive compensation and comprehensive benefits

Work with a global leader in healthcare and business services

Utilize your clinical expertise in a non-bedside nursing environment

Career growth and leadership development opportunities

Collaborative and supportive clinical team culture

Meaningful work that influences healthcare and disability-related decisions