Utilization and Denials Management Auditor

Manatal; Pateros; On-site; PHP 900,000 - 1,300,000; Full time

Benefits offered by this job

Healthcare coverage from day one

Dependent coverage

Paid time off with cash conversion

Group life insurance

Performance bonuses

Flexible work arrangements

Job summary

MicroSourcing is seeking a Utilization and Denials Management Auditor to support QA and daily operations within the Utilization Management team in the Philippines. The role involves auditing, training, and ensuring adherence to guidelines to optimize productivity and accuracy for client healthcare processes.

The ideal candidate is a BSN-educated RN with experience in Utilization Management or clinical denials, proficient in US guidelines and major EMRs, and capable of clear English

Qualifications

• BSN from an accredited program and active nursing license.

Responsibilities

• Support daily production and QA for Utilization and Denials Management.
• Assist in QA program design, auditing critical workflows.
• Monitor staff productivity and QA metrics.
• Escalate issues to Manager; coordinate with Training.
• Ensure documentation of medical diagnoses and treatments.
• Prepare training dashboards and participate in client calibration.

Skills

Utilization Mgmt

Clinical Appeals

QA Auditing

Nursing BSN

RN License

InterQual/MCG

EMR (Epic/Cerner/Meditech)

English Proficiency

Education

BSN degree

Tools

Epic

Cerner

Meditech

SharePoint

Excel

Job description

Discover your 100% YOU with MicroSourcing!

Position: Utilization and Denials Management Auditor

Location: Taguig, Philippines

Work setup & shift: PH Night Shift

Why join MicroSourcing? You'll have:

Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time-off with cash conversion, group life insurance, and performance bonuses.

A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company-sponsored events and activities.

Work-Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.

Career Growth: Take advantage of opportunities for continuous learning and career advancement.

Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.

Your Role:

As a Utilization and Denials Management Auditor, you will:

• Support the day-to-day production and quality functions of Utilization and Denials Management specialists to help meet client productivity and accuracy goals.
• Assist in QA program build, including identifying critical workflow areas to audit, defining effective audit attributes, and leveraging automation and efficiency tools.
• Monitor Utilization and Denials Management staff using key metrics, including Utilization Management and Clinical Denials & Appeals productivity and accuracy.
• Escalate production and QA concerns or roadblocks to the Manager and work with Training teams to communicate progress.
• Apply domain expertise in quality processes related to production schedules and documentation of medical diagnoses and treatment practices.
• Maintain a strong understanding of Utilization and Denials Management production and quality assurance processes and guidelines.
• Provide training, coaching, mentoring, and regular feedback to team members.
• Monitor and maintain team QA records, auditing results, and education findings.
• Complete full Utilization and Denials Management audits and other special projects as assigned.
• Review production, quality, accuracy, and system reports and share feedback on progress.
• Partner with global Operations, Training, and HR to streamline onboarding and on-the-job learning.
• Participate in client calibration calls to align training KPIs with operational metrics.
• Support client visits, internal audits, and process reviews by presenting training dashboards and achievements.
• Perform other duties and responsibilities as assigned.

What You Need:

Non-negotiables

• At least 1 year of Utilization Management and/or Clinical Appeals Writing QA or auditing experience in a healthcare setting.
• Minimum 3–5 years of acute care clinical experience in a hospital setting, with Med/Surg or similar preferred; 2–3 years if ICU experience.
• Bachelor of Science in Nursing (BSN).
• Must be a Registered Nurse with an active PHRN or USRN license.
• Proficiency in using InterQual or MCG clinical guidelines.
• Broad knowledge of U.S. Government Programs and Insurance Regulations.
• Proficiency with hospital-based EMR such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication and customer service skills, with a CEFR level of at least B2 for both verbal and written communication.

Preferred skills/expertise

• Master's degree or credential in business, healthcare, or a related field.
• Case management, clinical appeals, or clinical denials certification (ACMA preferred).
• Experience using computer programs for tracking authorization, denials, and appeals.
• Proficiency with Microsoft Office Suite, including Excel, Word, PowerPoint, Outlook, and SharePoint.
• Strong attention to detail, follow-up, and follow-through skills.
• Ability to make complex decisions independently using sound judgment and discretion.
• Demonstrated teamwork and integrity in all work-related activities.
• Ability to interact with internal and external customers in a professional manner.
• Strong analytical and critical-thinking skills.
• Experience in a matrixed environment.
• Excellent written and verbal communication skills, with the ability to create impactful presentations.

About MicroSourcing

With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines.

Our commitment to 100% YOU

MicroSourcing firmly believes that our company's strength lies in our people's diversity and talent. We are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.

At MicroSourcing, equality is not merely a slogan – it's our commitment. Our way of life. Here, we don't just accept your unique authentic self - we celebrate it, valuing every individual's contribution to our collective success and growth. Join us in celebrating YOU and your 100%!

For more information, visit https://www.microsourcing.com/

*Terms & conditions apply