Senior Quality Evaluator (Quality Auditor/ Quality Analyst)

Concentrix Philippines; Philippines; On-site; PHP 240,000 - 420,000; Full time

Job summary

Concentrix Philippines seeks a BS Nursing graduate with an active license for a Quality Assurance role focused on Utilization Management and CMS audits. On-site position requiring precise documentation, scoring, and adherence to healthcare guidelines.

You will monitor and audit inbound/outbound contacts, participate in calibration, and provide feedback to improve quality and regulatory compliance. Teamwork with nurses and auditors is essential.

Qualifications

• BS Nursing graduate with active license.
• Experience in Utilization Management and QA in healthcare.
• Knowledge of CMS Medicare Part C Appeals regulatory standards.

Responsibilities

• Quality Evaluation: monitor, evaluate and audit a sampling of calls, chats, and emails; calibrations and reporting results to stakeholders.
• Compliance and Documentation: adhere to CMS guidelines, maintain confidentiality, document interactions accurately and prepare reports for audits.
• Collaboration: provide feedback to nurses, case coordinators, and appeals representatives to support performance improvement and regulatory compliance.

Skills

Attention to detail

Documentation

Communication

Collaboration

Analytical thinking

MS Office

Education

BS Nursing degree

Active nursing license

Tools

Quality Audit Systems

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)