Utilization Management Quality Assurance Analyst

Job not on LinkedIn

🔥 0 minutes ago

🇵🇭 Philippines – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔧 QA Engineer (Quality Assurance)

🚫👨‍🎓 No degree required

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Perform quality assurance audits on completed prospective, concurrent, and retrospective utilization management reviews involving inpatient, outpatient, ambulatory, and ancillary services • Evaluate the accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes • Conduct quality audits of member and provider calls for adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards • Audit nurses processing appeals and grievances • Verify the accuracy, consistency, and integrity of operational data and quality reports • Identify audit findings, trends, risks, and process-improvement opportunities • Research, analyze, and evaluate data from multiple sources to identify discrepancies, trends, and operational issues • Monitor quality initiatives, outcomes, metrics, and objectives • Prepare reports, presentations, and materials communicating audit results and recommendations to management • Support root cause analysis and recommend corrective and preventive actions • Provide recommendations on UM policies and procedures, clinical documentation standards, benefit interpretation, regulatory and compliance requirements, and quality improvement initiatives • Assist in creating user guides, training manuals, and process documentation • Collaborate with leadership to identify operational challenges and recommend solutions • Support change management and project activities • Participate in User Acceptance Testing (UAT), system enhancements, and implementation projects • Assist with business requirements documentation and workflow improvement recommendations • Support process redesign to improve efficiency, accuracy, and quality outcomes • Partner with operations teams to validate report content, audit results, and quality findings • Communicate quality trends and performance-improvement opportunities to internal stakeholders and leadership • Maintain comprehensive knowledge of business operations, products, programs, organizational structure, and UM processes • Perform other duties and special projects as assigned

🎯 Requirements

• Bachelor's degree in Healthcare Administration, Nursing, Business Administration, Health Information Management, or related field preferred • Equivalent combination of education and experience may be considered • Minimum of 2 years of experience in U.S. Healthcare, UM account, quality background, with emphasis on Utilization Management (UM), Medical Management Operations, or Care Management/Managed Care environments • USRN License • Strong analytical and problem-solving capabilities • Excellent verbal and written communication skills, with the ability to communicate complex concepts clearly • Strong organizational and planning skills, with the ability to manage multiple priorities • High attention to detail and commitment to accuracy • Advanced proficiency in Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook • Ability to independently evaluate data and identify trends, gaps, and opportunities for improvement • Ability to work independently and collaboratively in a team environment • Strong interpersonal skills and ability to interact effectively with employees, leaders, and clients at all organizational levels • Flexibility and adaptability in a fast-paced and changing environment • Ability to create and maintain business requirements documents, training materials, and procedural guides • Understanding of quality assurance methodologies, audit principles, and continuous improvement practices • Knowledge of utilization management workflows, healthcare benefits, and regulatory requirements • Preferred: Quality Assurance (QA), auditing utilization management reviews and clinical documentation, managed care/health plan/third-party administration environments, process improvement or operational quality initiatives • Preferred systems knowledge: HealthEdge HRCM, GuidingCare, JIRA, and other utilization management platforms and workflow systems

🏖️ Benefits

• Full-Time position • Personalized site features mentioned, but no job-specific benefits or compensation extras are stated