Utilization and Denials Management Auditor

MicroSourcing International; Taguig; On-site; PHP 500,000 - 700,000; Full time

Benefits offered by this job

Healthcare coverage day one

Performance bonuses

Paid time-off

Life insurance

Job summary

MicroSourcing in Taguig, Philippines is seeking a Utilization and Denials Management Auditor to support daily production and QA functions, ensuring client productivity and accuracy targets are met.

The role requires nursing credentials (BSN) with active RN license (PHRN/USRN), experience in Utilization Management or clinical appeals QA, and proficiency with EMR systems (Epic/Cerner/Meditech). Night shift in PH with on-site work setup.

Qualifications

• At least 1 year of Utilization Management and/or Clinical Appeals QA auditing experience in a healthcare setting.
• 3-5 years of acute care clinical experience in a hospital setting; 2-3 years if ICU.
• Bachelor of Science in Nursing (BSN).
• Must be a Registered Nurse with an active PHRN or USRN license.
• Proficiency in 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 at CEFR B2 level.

Responsibilities

• 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 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 production and QA 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.

Skills

Utilization Management

Clinical Appeals QA

Nursing (BSN)

RN license

English proficiency

Education

BSN

RN license (PHRN/USRN)

Tools

Epic

Cerner

Meditech

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