Quality Analyst – Appeals & Grievances | US Healthcare

John Clements Consultants, Inc.; Taguig; Hybrid; PHP 420.000 - 600.000; Vollzeit

Zusammenfassung

John Clements Consultants, Inc. is seeking a Quality Analyst – Appeals & Grievances to support our US Healthcare operations.

The role focuses on reviewing appeal cases for accuracy, completeness, quality, and compliance with applicable requirements. Responsibilities include reviewing case documentation, evaluating against CMS and federal requirements, ensuring timeliness with SLAs, and identifying errors or opportunities for improvement.

Qualifikationen

• Associate degree graduate.
• 2+ years of experience in Quality Assurance, US Healthcare, Appeals & Grievances, Claims, Healthcare Operations, or Customer Service.
• US Healthcare experience is highly preferred.
• Experience reviewing, auditing, or quality-checking healthcare cases is an advantage.
• Knowledge of Medicare/Medicaid, Medicare Advantage, CMS requirements, or healthcare regulations is a strong advantage.
• Strong analytical and problem-solving skills.

Aufgaben

• Conduct quality reviews of Appeals & Grievances (A&G) cases for accuracy, completeness, and compliance.
• Review case documentation, including correspondence, determination letters, case notes, and supporting documents.
• Evaluate cases against organizational, client, CMS, state, and federal requirements.
• Verify that cases are processed within required timelines and service-level agreements (SLAs).
• Identify documentation errors, quality issues, compliance risks, and opportunities for process improvement.
• Monitor recurring quality issues and trends and recommend appropriate corrective actions.
• Escalate significant quality, compliance, or process concerns to the appropriate leadership team.
• Maintain confidentiality of member and health information in accordance with HIPAA and company policies.
• Work closely with the Appeals & Grievances Quality team and leadership to support consistent and accurate case handling.

Kenntnisse

Quality Assurance

US Healthcare

Appeals & Grievances

Healthcare Operations

Customer Service

Ausbildung

Associate degree

Jobbeschreibung

Job Description

• We are looking for a Quality Analyst – Appeals & Grievances to support our US Healthcare operations. The role is responsible for reviewing healthcare appeal cases to ensure accuracy, completeness, quality, and compliance with applicable requirements.

Key Responsibilities

• Conduct quality reviews of Appeals & Grievances (A&G) cases for accuracy, completeness, and compliance.

• Review case documentation, including correspondence, determination letters, case notes, and supporting documents.

• Evaluate cases against organizational, client, CMS, state, and federal requirements.

• Verify that cases are processed within required timelines and service-level agreements (SLAs).

• Identify documentation errors, quality issues, compliance risks, and opportunities for process improvement.

• Monitor recurring quality issues and trends and recommend appropriate corrective actions.

• Escalate significant quality, compliance, or process concerns to the appropriate leadership team.

• Maintain confidentiality of member and health information in accordance with HIPAA and company policies.

• Work closely with the Appeals & Grievances Quality team and leadership to support consistent and accurate case handling.

Qualifications

• At least Associate degree graduate

• 2+ years of experience in Quality Assurance, US Healthcare, Appeals & Grievances, Claims, Healthcare Operations, or Customer Service.

• US Healthcare experience is highly preferred.

• Experience reviewing, auditing, or quality-checking healthcare cases is an advantage.

• Knowledge of Medicare/Medicaid, Medicare Advantage, CMS requirements, or healthcare regulations is a strong advantage.

• Strong analytical and problem-solving skills.

Work Setup

• Initially Work From Home

• Night Shift

• Candidates must be flexible and willing to report onsite at least twice a week when required by the business/operations.