Performance Quality Auditor

Carelon Global Solutions; Philippines; On-site; PHP 600,000 - 800,000; Full time

Job summary

Carelon Global Solutions is seeking a Quality Auditor to evaluate the quality and accuracy of healthcare-related transactions and communications. The role requires 3 years in quality auditing, including at least 1 year in healthcare/insurance contexts, with strong ICD-10 and medical terminology knowledge.

The ideal candidate will identify issues, generate reports, and work onsite in the Philippines, collaborating with providers, groups, and policyholders to ensure prompt resolution and improved

Qualifications

• Active PHRN license required.
• Minimum of 3 years of relevant work experience, including at least 1 year in a Quality Audit role.
• Experience in Medical Coding, Chart Review, and Chart Auditing.
• Strong knowledge of ICD-10 coding standards, medical terminology, and healthcare documentation requirements.
• Experience in healthcare, insurance, claims processing, enrollment, billing, and customer service operations.
• Proficient in identifying quality issues, conducting audits, analyzing trends, and preparing audit reports.
• Willing to work under a 100% onsite work arrangement.

Responsibilities

• Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders.
• Identifies, documents, and reports any transaction errors or communications issues to ensure prompt resolution.
• Tracks and trends audit results, providing feedback to management.
• Identifies and reports on systemic issues which create ongoing quality concerns.
• Generates monthly reports of audit findings and supports clients with issues identified.
• Produces other ad hoc reports as requested by internal and external clients.
• Associates at this level conduct routine to complex audits for one or more systems platforms and lines of business.

Skills

Quality audit

Chart review

Healthcare terminology

Education

PHRN license

Tools

ICD-10 coding standards

Medical terminology

Job description

Responsible for evaluating the quality of services and interactions provided by organizations within the enterprise. Included are processes related to enrollment and billing and claims processing, as well as customer service written and verbal inquiries. Primary duties may include, but are not limited to: Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders. Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Identifies and reports on systemic issues which create ongoing quality concerns. Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested. Produces other ad hoc reports as requested by internal and external clients. Associates at this level conduct routine to complex audits, generally related to one or more functions on one or more systems platform for one or more lines of business. Requires a BA/BS degree; 3 years of experience including a minimum of 1 year of related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background. Working knowledge of insurance industry and medical terminology, detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines; and ability to acquire and perform progressively more complex skills and tasks in a production environment required.

Qualifications

• Active PHRN (Philippine Registered Nurse) License is required.

• Minimum of 3 years of relevant work experience, including at least 1 year in a Quality Audit role.

• Experience in Medical Coding, Chart Review, and Chart Auditing.

• Strong knowledge of ICD-10 coding standards, medical terminology, and healthcare documentation requirements.

• Experience in healthcare, insurance, claims processing, enrollment, billing, and customer service operations.

• Proficient in identifying quality issues, conducting audits, analyzing trends, and preparing audit reports.

• Willing to work under a 100% onsite work arrangement.