Utilization Management QA Analyst – Process Improvement

UST

Philippines

On-site

PHP 450,000 - 750,000

Full time

9 days ago

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Job summary

UST is seeking a Utilization Management Quality Assurance Analyst in the Philippines to support quality improvement through audits, data analysis, and policy compliance. You will collaborate with leadership and operations to evaluate performance, communicate findings, and drive process enhancements across UM reviews and related documentation.

Required two years in U.S. healthcare UM or similar quality roles, USRN license, and strong skills in analytics, communication, and MS Office.

Qualifications

Bachelor's degree in a health admin, nursing, business, or related field preferred; equivalent combos may be considered.
Minimum of 2 years of experience in U.S. Healthcare, UM, quality background with emphasis on UM/MCO environments.
Experience auditing utilization management reviews and clinical documentation is preferred.
Knowledge of QA methodologies, audit principles, and regulatory requirements.

Responsibilities

Perform QA audits of completed prospective, concurrent, and retrospective UM reviews across inpatient, outpatient, ambulatory, and ancillary services.
Evaluate accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes.
Audit member and provider calls for policy, benefits, regulatory, and service standards adherence.
Prepare reports and communicate audit results and recommendations to management.
Support root cause analysis and corrective/preventive actions.
Assist in creating user guides, training materials, and process documentation.
Collaborate with leadership to identify operational challenges and improvement opportunities.