Remote Night-Shift QA Analyst - Appeals & Grievances

John Clements Consultants, Inc.; Taguig; Remote; PHP 350.000 - 550.000; Vollzeit

Zusammenfassung

John Clements Consultants, Inc. is recruiting a Quality Analyst for a leading US healthcare organization. You will audit completed member appeal cases to ensure accuracy, timeliness, and regulatory compliance.

In this role, you will verify case documentation against CMS, HIPAA, and client requirements, monitor processing timelines, and identify opportunities for process improvements. Night shift work and remote setup with occasional onsite visits are supported.

Qualifikationen

• 2+ years in quality assurance, auditing, or compliance review.
• Healthcare/Appeals knowledge is preferred.
• Strong analytical and problem solving with attention to detail.
• Effective written and verbal communication.

Aufgaben

• Audit completed member appeal cases for accuracy, completeness and regulatory compliance.
• Check case documentation against CMS, HIPAA, state/federal and client requirements.
• Audit correspondence, determination letters, case notes and supporting documents.
• Verify case processing timelines and SLAs were 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 systemic issues to leadership.
• Protect member and health information in line with HIPAA requirements.

Kenntnisse

Quality assurance

Regulatory compliance

Analytical thinking

Attention to detail

Written communication

MS Office

Ausbildung

Associate's degree

Bachelor's degree

Jobbeschreibung

John Clements Consultants, Inc. is recruiting a Quality Analyst for a leading US healthcare organization. You will audit completed member appeal cases to ensure accuracy, timeliness, and regulatory compliance.

In this role, you will verify case documentation against CMS, HIPAA, and client requirements, monitor processing timelines, and identify opportunities for process improvements. Night shift work and remote setup with occasional onsite visits are supported.