Utilization and Denials Management Auditor

MicroSourcing; Philippines; On-site; PHP 520,000 - 760,000; Full time

Job summary

MicroSourcing is seeking a Utilization and Denials Management Auditor to lead a onsite night-shift QA team in BGC, Taguig City. You will oversee daily production and QA to ensure client accuracy and performance goals are met, coaching staff and driving audit quality.

The role requires 1+ year QA in utilization management or clinical appeals, 3–5 years acute care experience or 2–3 years ICU, and a BSN with active PHRN/USRN license.

Qualifications

• 1 year QA in utilization management or clinical appeals in healthcare.
• 3–5 years acute care hospital experience or 2–3 years ICU experience.
• BSN with active PHRN or USRN license.
• Strong understanding of InterQual or MCG guidelines and US insurance/government healthcare programs.
• Experience with EMR systems such as Epic, Cerner, or Meditech.
• Excellent English communication skills (CEFR B2).

Responsibilities

• Oversee day-to-day production and quality functions of a team of specialists to meet client accuracy and performance goals.
• Monitor staff performance using metrics like productivity and accuracy for clinical denials and appeals.
• Support QA program development and audit design, including automation improvements.
• Provide coaching, training, and ongoing feedback to improve team performance.
• Review production and quality reports, conduct performance evaluations, and lead monthly team meetings.
• Maintain QA records and audit findings; support special projects including full utilization and denials audits.
• Partner with global Operations, Training, and HR to improve onboarding and processes.
• Participate in client calibration sessions to align KPIs and expectations.
• Support internal audits and client visits by presenting dashboards and achievements.

Skills

QA Experience

Clinical Experience

Communication (English)

RCM Knowledge

Education

BSN with active PHRN/USRN

Tools

Epic

Cerner

Meditech

Job description

Position: Utilization and Denials Management Auditor

Location: BGC, Taguig City

Work setup & shift: Onsite, Night shift

Your Role

As a Utilization and Denials Management Auditor, you will oversee the day-to-day production and quality functions of a team of specialists to ensure client accuracy and performance goals are met.

You Will

• Monitor staff performance using key metrics such as productivity and accuracy for Clinical Denials and Appeals
• Support the development and maintenance of the QA program, including audit design and automation improvements
• Provide coaching, training, and ongoing feedback to improve team performance
• Review production and quality reports, conduct performance evaluations, and facilitate monthly team meetings
• Maintain QA records, audit findings, and support special projects including full utilization and denials audits
• Partner with global Operations, Training, and HR teams to improve onboarding and processes
• Participate in client calibration sessions to align KPIs and expectations
• Support internal audits and client visits by presenting dashboards, reports, and achievements

Required Qualifications

• QA Experience: At least 1 year of utilization management and/or clinical appeals QA or auditing experience in a healthcare setting
• Clinical Experience: 3–5 years acute care hospital experience (Med/Surg preferred) or 2–3 years ICU experience
• Education & License: Bachelor of Science in Nursing with active PHRN or USRN license
• RCM Knowledge: Strong understanding of InterQual or MCG clinical guidelines and US insurance and government healthcare programs
• Systems: Experience with EMRs such as Epic, Cerner, or Meditech
• Communication: Excellent English communication skills (minimum CEFR B2)

Preferred Skills

• Advanced Education: Master’s degree or related postgraduate qualification in healthcare or business
• Certification: Case management, clinical appeals, or denials certification (e.g., ACMA)
• Tools: Proficiency in Microsoft Office and tracking systems for authorizations or denials
• Soft Skills: Strong analytical thinking, independent judgment, and presentation skills