Job Description

We are looking for an experienced USRN Quality Assurance Analyst to join our Healthcare Account team. This role is responsible for ensuring clinical accuracy, documentation quality, regulatory compliance, and excellent service delivery across U.S. healthcare processes.

Key Responsibilities

Clinical Quality Auditing & Evaluation

• Perform quality audits of clinical processes including:
  • Utilization Management (UM)
  • Case Management (CM)
  • Clinical Triage
  • Medical Necessity Reviews
  • Clinical Documentation Reviews
• Evaluate clinical decisions, documentation accuracy, and adherence to U.S. healthcare standards.
• Ensure compliance with guidelines such as:
  • MCG/Milliman
  • InterQual
  • CMS requirements
  • Client-specific clinical policies
• Review medical records and documentation for completeness, accuracy, and compliance.
• Validate appropriate use of clinical criteria, medical terminology, and healthcare workflows.

Coaching & Performance Improvement

• Provide clear, objective, and timely feedback based on audit results.
• Partner with Operations Leaders, Trainers, and Clinical SMEs to improve team performance.
• Identify knowledge gaps and recommend training or corrective actions.
• Support nurses in improving clinical reasoning and documentation practices.

Quality Reporting & Analysis

• Create quality reports, audit summaries, scorecards, and performance trend reports.
• Conduct root cause analysis (RCA) for recurring quality issues.
• Identify process gaps and recommend solutions to improve clinical outcomes.
• Participate in calibration sessions with internal teams and clients.

Compliance & Process Improvement

• Ensure compliance with HIPAA, privacy standards, and U.S. healthcare regulations.
• Support internal and external audits.
• Contribute to the improvement of QA tools, workflows, SOPs, and clinical guidelines.
• Participate in continuous improvement projects and quality initiatives.

Qualifications & Requirements

Mandatory Requirements

• Philippine Registered Nurse (RN) license required.
• Active and unrestricted US Registered Nurse (USRN) license required.
• Minimum 2 years of clinical bedside experience, preferably in:
  • Emergency Room (ER)
  • ICU
  • Medical-Surgical
  • Telemetry
• Minimum 1 year of US Healthcare BPO experience in areas such as:
  • Utilization Management (UM)
  • Case Management (CM)
  • Appeals
  • Clinical Review
  • Triage
  • Related clinical processes
• Previous experience as:
  • Quality Analyst
  • Clinical Auditor
  • Clinical Reviewer
  • QA Specialist in a healthcare account

Required Skills

• Strong knowledge of:
  • U.S. healthcare processes
  • HIPAA regulations
  • Medical terminology
  • Care coordination
  • Clinical documentation standards
  • Healthcare compliance
• Familiarity with:
  • ICD-10
  • CPT coding
  • MCG/Milliman
  • InterQual guidelines
• Strong analytical skills and attention to detail.
• Excellent written and verbal English communication skills.
• Comfortable handling calls, documentation reviews, and high-volume email communication.
• Ability to work under pressure in a fast-paced healthcare environment.
• Proficiency in MS Office and QA evaluation systems.