Remote Appeals & Grievances QA Associate III

John Clements Consultants, Inc.; Taguig; Hybride; PHP 279 000 - 502 000; Plein temps

Résumé du poste

John Clements Consultants, Inc. seeks an Appeals and Grievances Associate III to review appeal cases for regulatory compliance and quality standards.

You will perform quality audits, identify improvement opportunities, and support timely, compliant handling in collaboration with the Quality Team and Supervisor. Ideal candidates have 2+ years in quality assurance or healthcare operations, strong analytical skills, and proficiency in MS Office.

Qualifications

• 2+ years in quality assurance, appeals and grievances, healthcare operations, claims or customer service
• Basic understanding of healthcare regulations and compliance requirements
• Strong analytical and problem-solving skills
• Excellent attention to details and accuracy
• Effective written and verbal communication skills
• Proficiency in MS Office

Responsabilités

• Conduct quality reviews of appeals cases for accuracy, completeness, and regulatory compliance
• Evaluate case documentation against organizational, CMS, state, federal, and client requirements
• Audit correspondence, determination letters, case notes, and supporting documentation
• Verify case processing timeliness and SLAs are met
• Identify errors, compliance risks, and process improvement opportunities
• Monitor trends and recommend corrective actions for recurring quality issues
• Escalate high-risk findings, compliance concerns, and systematic issues to leadership
• Maintain confidentiality of member and health information per HIPAA requirements

Connaissances

Quality assurance

Healthcare operations

Analytical skills

Attention to detail

Communication skills

MS Office

Time management

Formation

Associate's degree preferred

Outils

MS Office

Description du poste

John Clements Consultants, Inc. seeks an Appeals and Grievances Associate III to review appeal cases for regulatory compliance and quality standards.

You will perform quality audits, identify improvement opportunities, and support timely, compliant handling in collaboration with the Quality Team and Supervisor. Ideal candidates have 2+ years in quality assurance or healthcare operations, strong analytical skills, and proficiency in MS Office.