Utilization & Denials Auditor — QA & Compliance Expert

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

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.