Work Setup: On-site

Location: Quezon City

Shift: Night Shift

Salary Range: ₱60,000 – ₱90,000

Start Date: December 31, 2025 / ASAP

Recruitment Process: Two-stage virtual interview

Qualifications

• 
  

  Bachelor’s Degree in Nursing with an active and valid USRN license (Massachusetts)

  
  


• 
  

  Minimum of 1 year of experience in the Appeals and Grievances workstream, specifically focused on Medicare Part C Appeals

  
  


• 
  

  1–2 years of experience as a Quality Assurance Specialist or Quality Evaluator in a clinical BPO/CPO environment

  
  


• 
  

  Strong knowledge of CMS Medicare Part C Appeals regulatory standards

  
  


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  Solid understanding of clinical terminology, medical necessity review principles, and healthcare insurance operations

  
  


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  Experience supporting external audits, including CMS Program Audits and client-led audits

  
  


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  Proven background in mentoring or coaching new quality staff

  
  


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  Excellent verbal and written communication skills

  
  


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  High attention to detail with strong documentation, writing, scoring calibration, and quality review abilities

  
  


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  Proficient in Quality Audit Systems and Microsoft Office applications

  
  


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  Strong analytical, critical thinking, and problem-solving skills

  
  


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  InterQual experience of at least 1 year (Medicare and Medicaid)

  
  


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  Willingness to work on-site with flexible schedules, including US hours and holidays

  
  


• 
  

  Open to working night shift with fixed weekends off

  
  

Pre-Screening Questions

1. 
   

   Do you have an active USRN license?

   
   


2. 
   

   How many years of experience do you have in Clinical Appeals and Grievances?

   
   


3. 
   

   How many years of experience do you have as a Quality Assurance Specialist or Quality Evaluator in a clinical BPO/CPO setting?

   
   


4. 
   

   How would you rate your knowledge of CMS Medicare Part C Appeals regulatory standards (1–10)?

   
   


5. 
   

   Do you have experience supporting CMS Program Audits or client audits?

   
   


6. 
   

   How would you rate your understanding of healthcare insurance processes, including appeals, grievances, and utilization management (1–10)?

   
   


7. 
   

   Do you have InterQual experience?