Quality Analyst (Clinical Claims)

Sutherland; Pateros; On-site; PHP 350,000 - 550,000; Full time

Job summary

Sutherland in the Philippines is seeking a Quality Analyst to monitor, evaluate, and improve the quality of clinical claim operations within the AO Clinical Claim Program. You will work with Operations, Training, and Clinical Teams to identify improvements and drive quality excellence.

The role requires an active USRN license, 2+ years clinical experience, and 1+ year QA experience in healthcare/claims. Strong auditing, analytics, and communication skills are essential, with a focus on

Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Minimum 2 years of recent clinical experience in healthcare settings.
• At least 1 year of Quality Analyst experience in a BPO/healthcare/claims environment.
• Strong understanding of healthcare documentation and claim review processes.
• Knowledge of quality methodologies, auditing principles, and root cause analysis.
• Excellent analytical, coaching, and communication skills.

Responsibilities

• Monitor, evaluate, and improve the quality of clinical claim operations.
• Maintain quality scorecards and audit documentation.
• Analyze quality trends, root causes, and performance gaps; present findings to leaders.
• Provide feedback and develop performance improvement plans with managers.
• Ensure HIPAA compliance and adherence to client policies and internal standards.
• Collaborate with Operations, Training, and Client Services teams.

Skills

Clinical experience

Quality Analyst experience

Auditing

Analytical skills

Communication

Education

USRN license

Tools

Excel

PowerPoint

Job description

Company Description:

About Sutherland

Artificial Intelligence. Automation. Cloud engineering. Advanced analytics. For business leaders, these are key factors of success. For us, they’re our core expertise.
We work with iconic brands worldwide. We bring them a unique value proposition through market-leading technology and business process excellence.

We’ve created over 200 unique inventions under several patents across AI and other critical technologies. Leveraging our advanced products and platforms, we drive digital transformation, optimize critical business operations, reinvent experiences, and pioneer new solutions, all provided through a seamless “as a service” model.

For each company, we provide new keys for their businesses, the people they work with, and the customers they serve. We tailor proven and rapid formulas, to fit their unique DNA. We bring together human expertise and artificial intelligence to develop digital chemistry. This unlocks new possibilities, transformative outcomes and enduring relationships.

Sutherland
Unlocking digital performance. Delivering measurable results.

Job Description:

The Quality Analystis responsible for monitoring, evaluating, and improving the quality of clinical claim operations within an AO Clinical Claim Program. This role ensures that claims reviews, medical documentation assessments, customer interactions, and operational processes meet client requirements, regulatory standards, and internal quality expectations. The Quality Analyst partners closely with Operations, Training, and Clinical Teams to identify improvement opportunities, provide actionable feedback, and drive continuous quality excellence.

Key Responsibilities

Quality Monitoring & Evaluation

• Conduct regular audits of clinical claim reviews and related transactions.
• Evaluate adherence to client guidelines, operational procedures, and quality standards.
• Assess documentation accuracy, completeness, and compliance with established workflows.
• Ensure consistency in claim review decisions and quality outcomes.

Reporting & Analysis

• 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.

Coaching & Feedback

• Provide timely and constructive feedback to Clinical Claims Associates and Nurses.
• Partner with Team Managers in developing performance improvement plans.
• Support calibration sessions to ensure scoring consistency among quality evaluators.
• Identify learning opportunities and collaborate with Training teams.

Compliance & Process Excellence

• Ensure compliance with HIPAA, client policies, applicable healthcare regulations, and internal standards.
• Participate in process improvement initiatives to enhance quality, productivity, and customer experience.
• Support implementation of quality frameworks and continuous improvement programs.
• Escalate critical quality and compliance issues appropriately.

Stakeholder Management

• Collaborate with Operations, Training, Workforce Management, and Client Services teams.
• Participate in client calibrations and quality discussions as needed.
• Contribute to business reviews and quality governance activities.

Qualifications:

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Minimum 2 years of recent clinical experiencein hospital, utilization management, case management, disability, health insurance, or related healthcare settings.
• At least 1 year of Quality Analyst experiencein a BPO, healthcare, insurance, claims, or clinical operations environment.
• Strong understanding of healthcare documentation, claim review processes, and medical terminology.
• Knowledge of quality methodologies, auditing principles, and root cause analysis.
• Excellent analytical, coaching, and communication skills.
• Experience in performance monitoring, quality scorecards, and reporting.
• Proficiency in Microsoft Office applications, particularly Excel and PowerPoint.
• Ability to work independently and manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Experience supporting Disability Claims, Clinical Claims, Group Benefits, or Insurance Operationsaccounts.
• Knowledge of disability management or absence management programs.
• Experience handling quality calibrations and client-facing quality reviews.
• Lean Six Sigma Yellow Belt or equivalent quality certification.
• Experience using quality management systems and reporting tools.

Additional Information:

Internal Qualifications:

• Must have Annual PDP score of Exceeds Expectations (4) or Outstanding (5)
• Tenure of at least 12months on the current role
• No Active DA