Job Title: USRN Quality Assurance Specialist

Shift: Night shift

Work Set-up: On-site in  Bridgetowne, Quezon City

Salary range:  60K to 90K

Start date: ASAP

Recruitment Process: 2  Virtual interview processes

QUALIFICATIONS:

• Bachelor's Degree in Nursing with an active and valid license in USRN Massachusetts

• Minimum of 1 year experience in appeals and  grievances  workstream with focus on Medicare Part C Appeals

•At least  1 year to 2 years experience as  a Quality Assurance or Quality  Evaluator in a clinical BPO or  CPO setting

• In-depth knowledge and understanding  of CMS Medicare Part C Appeals  regulatory standards

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

• Experience supporting external audits (CMS  Program Audits) and Client Audits

•  Must have an experience in mentoring or coaching new quality staff

• Excellent verbal and written communication skills

• High  attention to detail with strong documentation, writing, and scoring calibration skills

• Proficiency in Quality Audit Systems and Microsoft Office Suite

•  Strong analytical, critical thinking and problem solving  skills

• Excellent communication, coaching, and collaboration abilities

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

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

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 or Quality  Evaluator in a clinical BPO or  CPO setting?

4. Rate your knowledge and understanding  of CMS Medicare Part C Appeals  regulatory standards, from 1 to 10, 10 being the highest.

5.Do you have experience supporting external audits (CMS  Program Audits) and Client Audits?

6. Please rate your knowledge and understanding of different healthcare insurance processes, appeals, grievances, and utilization management, from 1 to 10, 10 being the highest.

7. Do you have InterQual experience?

8. How much is your last drawn salary?

9. How much is your salary expectation?

10. Are you amenable to working onsite in Bridgetowne, Quezon City, with a night shift and fixed weekends off schedule?

11. This is an urgent hiring. Can you start  on Dec 31st,  2025?