USRN Quality Assurance Specialist

Gratitude Inc

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4 days ago

USRN Quality Assurance Specialist

1-3 Year(s)

60 - 90 Thousand p.m

Manila

Job Description

Key Skills

USRN Utilization Management Clinical Denials and appeals InterQual Process Grievances Support Experience Quality Assurance in BPO/CPO

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Job Title: USRN Quality Assurance Specialist

Shift: Night shift

Work Set-up: On-site in Bridgetowne, Quezon City

Salary range: 60K to 90K

Start date: ASAP

Recruitment Process: 2 Virtual interview processes

QUALIFICATIONS:

• Bachelor's Degree in Nursing with an active and valid license in USRN Massachusetts

• Minimum of 1 year experience in appeals and grievances workstream with focus on Medicare Part C Appeals

•At least 1 year to 2 years experience as a Quality Assurance or Quality Evaluator in a clinical BPO or CPO setting

• In-depth knowledge and understanding of CMS Medicare Part C Appeals regulatory standards

• Strong understanding of clinical terminology, medical necessity review principles and healthcare insurance operations

• Experience supporting external audits (CMS Program Audits) and Client Audits

• Must have an experience in mentoring or coaching new quality staff

• Excellent verbal and written communication skills

• High attention to detail with strong documentation, writing, and scoring calibration skills

• Proficiency in Quality Audit Systems and Microsoft Office Suite

• Strong analytical, critical thinking and problem solving skills

• Excellent communication, coaching, and collaboration abilities

• InterQual experience of at least 1 year (Medicare and Medicaid)

• Willingness to work on-site with flexible schedules, including US hours and holidays

PRE-SCREENING QUESTIONS:

1. Do you have an active USRN license?

2. How many years of experience do you have in clinical appeals and grievances ?

3. How many years of experience do you have as a Quality Assurance or Quality Evaluator in a clinical BPO or CPO setting?

4. Rate your knowledge and understanding of CMS Medicare Part C Appeals regulatory standards, from 1 to 10, 10 being the highest.

5.Do you have experience supporting external audits (CMS Program Audits) and Client Audits?

6. Please rate your knowledge and understanding of different healthcare insurance processes, appeals, grievances, and utilization management, from 1 to 10, 10 being the highest.

7. Do you have InterQual experience?

8. How much is your last drawn salary?

9. How much is your salary expectation?

10. Are you amenable to working onsite in Bridgetowne, Quezon City, with a night shift and fixed weekends off schedule?

11. This is an urgent hiring. Can you start on Dec 31st, 2025?

Role

QA/QC Exec.

Timings

Night Shift (Contract To Hire)

Industry

BPO

Work Mode

Work from office

Process

Voice

Functional Area

ITES / BPO / Customer Service

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