Clinical Claims Quality Analyst - HIPAA Compliance (US RN)

SmartRecruiters, Inc.; Taguig; On-site; PHP 480,000 - 640,000; Full time

Job summary

Sutherland is looking for a Quality Analyst (Clinical Claims) - Pooling to monitor, evaluate, and improve the quality of clinical claim operations within an AO Clinical Claim Program. You will audit claims reviews, assess documentation, and ensure compliance with HIPAA, client policies, and internal standards.

You’ll partner with Operations, Training, and Clinical Teams to drive continuous quality improvement.

Qualifications

• Active USRN license required.
• 2+ years of clinical experience in hospital, utilization management, case management, disability, health insurance, or related healthcare settings.
• At least 1 year of Quality Analyst experience in a BPO, healthcare, insurance, claims, or clinical operations environment.
• Strong understanding of healthcare documentation, claim review processes, and medical terminology.

Responsibilities

• Conduct regular audits of clinical claim reviews and related transactions.
• Evaluate adherence to client guidelines, procedures, and quality standards.
• Assess documentation accuracy, completeness, and compliance with established workflows.
• Ensure consistency in claim review decisions and quality outcomes.
• Maintain quality scorecards and audit documentation.
• Analyze quality trends, root causes, and performance gaps.
• Prepare and present quality reports to Operations leaders and stakeholders.
• Recommend corrective and preventive actions based on audit findings.

Skills

Active USRN license

2+ years clinical experience

Quality Analyst experience

Healthcare documentation

Root cause analysis

MS Excel

PowerPoint

Communication skills

Multitasking

Education

Nursing degree

Tools

Quality management systems

Job description

Sutherland is looking for a Quality Analyst (Clinical Claims) - Pooling to monitor, evaluate, and improve the quality of clinical claim operations within an AO Clinical Claim Program. You will audit claims reviews, assess documentation, and ensure compliance with HIPAA, client policies, and internal standards.

You’ll partner with Operations, Training, and Clinical Teams to drive continuous quality improvement.