About the Company 

We are a global healthcare BPO partner working with U.S.-based clients, providing utilization management, appeals and grievances processing, and clinical review services. We uphold the highest standards of compliance, quality, and efficiency ensuring that our processes meet U.S. regulatory requirements (e.g., Medicare). Our organization values professionalism, clinical excellence, continuous learning, and collaboration across teams to deliver top-class service to clients and patients.

Role Overview 

We are looking for a licensed U.S. Registered Nurse (USRN) to join our team as a Quality Assurance Specialist. In this role, you will review, audit, and quality-check appeals, grievances, and clinical cases (particularly Medicare Part C Appeals), ensuring compliance with regulatory standards and client requirements. You’ll also mentor/co-coach junior quality staff, participate in audits, and collaborate closely with cross-functional teams to uphold consistent and high-quality outputs.

Key Responsibilities 

• Perform quality audits and reviews of appeals, grievances, and clinical case work, focusing on Medicare Part C Appeals.


• Ensure compliance with CMS regulatory standards, internal policies, and client guidelines.


• Use Quality Audit systems and Microsoft Office Suite (and other tools) to document, score, and report audit results.


• Support external (e.g., CMS) and client audits when required.


• Mentor and coach junior or new quality staff ensuring consistent evaluation and calibration of scoring.


• Collaborate with other teams to maintain efficient workflow, accurate documentation, and timely processing of tasks.


• Provide clear, well-written documentation of audit findings, feedback, and process improvement suggestions.


• Work night shift, adhering to US business hours and holiday coverage as needed.

Candidate Qualifications

• Bachelor’s Degree in Nursing with an active and valid USRN license (Massachusetts or appropriate U.S. state).


• At least 1 year of experience in appeals and grievances workstream — preferably with focus on Medicare Part C Appeals.


• At least 1–2 years experience in a Quality Assurance or Quality Evaluator role within a clinical BPO or CPO setting.


• Strong knowledge of clinical terminology, medical necessity review principles, healthcare insurance operations.


• Experience supporting external audits (e.g., CMS Program Audits) and client audits.


• Proven experience in mentoring or coaching quality staff.


• High attention to detail, strong documentation, writing, scoring/calibration skills.


• Proficiency in quality audit systems and Microsoft Office Suite.


• Strong analytical thinking, critical reasoning, problem-solving skills, and ability to collaborate.


• Excellent verbal and written communication skills.


• Willingness to work onsite in Bridgetowne, Quezon City with night shifts and fixed weekends off schedule.


• Ready to start on or around December 31, 2025 or as soon as possible.