Senior Quality Evaluator (PHRN Quality Auditor/ Quality Analyst)

Concentrix Philippines; Quezon City; On-site; PHP 335,000 - 603,000; Full time

Benefits offered by this job

Industry experts

Learning & development

Fun working environment

Job summary

Concentrix Philippines is seeking a Quality Evaluator with a BS Nursing degree and active license to support utilization management and QA activities. The role requires auditing calls, chats, and emails, ensuring CMS compliance, and documenting interactions for audits.

Ideal candidates have 1 year of QA or utilization management experience in a contact center, strong writing and analytical skills, and are willing to work on-site with US hours and holidays.

Qualifications

• BS Nursing degree with active license.
• At least 1 year of Utilization Management experience.
• At least 1 year in a QA/Quality Evaluator role in a contact center.
• Solid knowledge of CMS Medicare Part C Appeals regulations and clinical terminology.
• Strong documentation, writing, and scoring calibration skills.
• Willing to work on-site with US hours and holidays.

Responsibilities

• Quality evaluation of inbound/outbound calls, chats, and emails; participate in calibration and listening sessions with quality staff and client teams.
• Ensure compliance with CMS guidelines and document interactions and resolutions in the system; prepare reports for audits.
• Provide feedback to teams to improve processes and support audit readiness.

Skills

Quality Assurance

Documentation

Analytical Thinking

Communication

Education

BS Nursing

Tools

Microsoft Office

Job description

Are you ready to POWER UP your skills? Take the leap and join Concentrix's League of TOP-NOTCH TALENTS! Prepare for an Extra-Ordinary Journey where you not only Collaborate with Industry Champions but also immerse yourself in an Innovative Workplace filled with Laughter, Continuous Learning, and Limitless Opportunities. Join the Leading Global Provider of CX and Tech Services and seize this moment to #JoinConcentrix!

Essential Duties and Responsibilities:

• Quality Evaluation: Monitor(s), Evaluate(s) and Audit(s) a Sampling of Inbound or Outbound Call(s) and Other Contact Method(s) Including Chat(s) and Email(s), Participate in Calibration and Call Listening Session(s) with Quality Staff, Delivery, and Client(s) to Ensure Scoring Consistency and Best Practice(s) - Participate in Internal Quality Audit(s) Designed to Improve Overall Contact Quality and Recommend Change(s), Meet Audit Requirement(s) and Report Result(s) of Evaluation(s) to Stakeholder(s)

• Compliance and Documentation: Adhere to all CMS (Center(s) for Medicare and Medicaid Service(s)) Guideline(s) and Company Policies, Maintain Confidentiality of Sensitive Member Information - Accurately Document all Interaction(s) and Resolution(s) in the System, Prepare Report(s) as Required to Support Compliance and Auditing Requirement(s)

• Collaboration: Provide Insight(s) and Feedback on Recurring Issue(s) to Improve Process(es), Provide Structured Feedback to Appeals Nurse(s), Case Coordinator(s), as well as Appeals Representative(s) to Support Performance Improvement and Regulatory Compliance, Collaborate with Training and Operations to Identify Learning Gap(s) and Provide Input on Ongoing Upskilling Initiative(s), Support Audit Readiness for Client Review(s), Internal Audit(s), and Compliance Assessment(s)

Minimum Hiring Qualifications:

• BS Nursing graduate with active license

• 1 Year(s) Minimum Experience in Utilization Management

• 1 Year(s) Experience in a Similar Role or Function in a Contact Center Setting (Quality Assurance or Quality Evaluator)

• In-Depth Knowledge and Understanding of CMS Medicare Part C Appeals Regulatory Standard(s), Strong Understanding of Clinical Terminology, Medical Necessity Review Principle(s), and Healthcare Insurance Operations, Experience Supporting External Audit(s) (CMS Program Audit(s) and Client Audit(s)), and Mentoring or Coaching New Quality Staff

• High Attention to Detail with Strong Documentation, Writing, and Scoring Calibration Skills, Proficiency in Quality Audit System(s) and Microsoft Office Suite, Strong Analytical, Critical Thinking, and Problem Solving Skills, Excellent Communication, Coaching, and Collaboration Abilities

• Willing to Work On-Site with Flexible Work Schedule(s) Including US Hour(s) and Holiday(s)

Get Hired and Enjoy the Following:

• Interact/Collaborate and Learn from Industry Experts

• Multiple Opportunities for Learning and Development

• Enjoy a Fun - and Competitive Working Environment

Work Location: Tera Tower, Bridgetowne, Quezon City (onsite)