We are seeking a USRN Quality Assurance Analyst to ensure clinical quality, compliance, and documentation accuracy across U.S. Healthcare programs. This role is responsible for auditing Utilization Management (UM), Case Management (CM), Clinical Appeals, Triage, and other clinical workflows while ensuring adherence to HIPAA, MCG/Milliman, InterQual, and client-specific guidelines. The ideal candidate has strong clinical auditing experience, excellent analytical skills, and a background in U.S. Healthcare BPO operations.

Responsibilities

• Conduct clinical quality audits for Utilization Management (UM), Case Management (CM), Clinical Triage, Medical Necessity Reviews, and Clinical Documentation.

• Ensure compliance with MCG/Milliman, InterQual, CMS regulations, HIPAA, and client-specific quality standards.

• Validate clinical documentation, medical necessity, level of care, and coding accuracy (ICD-10/CPT where applicable).

• Provide structured feedback, coaching, and recommendations to improve clinical performance and documentation quality.

• Prepare quality reports, audit summaries, error trend analyses, and support root cause analysis (RCA).

• Collaborate with Operations, Training, and Clinical SMEs to drive continuous quality improvement initiatives.

• Participate in calibration sessions, internal and external audits, and process improvement projects.

• Support the development of SOPs, audit tools, and clinical quality standards.

Work Schedule

• Shift: GY (Night Shift)

• Work Set-up: TP Alphaland, Makati

• Start Date: ASAP

If you are a PH Registered Nurse with an active and unrestricted USRN license, experience in Quality Assurance, Clinical Auditing, or U.S. Healthcare BPO, and expertise in Utilization Management, Case Management, Clinical Appeals, or Triage, we'd love to hear from you.

Apply today by submitting your updated CV.