PHRN Quality Analyst (BPO Healthcare)

Carelon Global Solutions Philippines; Taguig; On-site; PHP 335,000 - 781,000; Full time

Job summary

Carelon Global Solutions Philippines seeks a Quality Audit Specialist to evaluate the quality and accuracy of transactions and communications within healthcare and insurance processes. You will identify issues, generate reports, and support management with audit findings, focusing on enrollment, billing, and claims processing.

The role emphasizes on-site work, detailed auditing, and collaboration with cross-functional teams to improve quality and compliance in client engagements.

Qualifications

• BA/BS degree and 3 years of experience in quality audit (1 year in QA role)
• Active PHRN license required
• Experience in medical coding, chart review, and chart auditing
• Strong knowledge of ICD-10, 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 100% onsite

Responsibilities

• Evaluate the quality and accuracy of transactions and communications with providers, groups, and policyholders.
• Identify, document, and report errors to ensure prompt resolution.
• Track audit results and provide feedback to management.
• Produce monthly audit reports and ad hoc reports for clients.

Skills

Quality audit

Medical coding

Chart review

Chart auditing

ICD-10 coding

Healthcare terminology

Auditing

Customer service

Education

BA/BS degree

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.