Clinical Quality Analyst - US Registered Nurses in the PHILIPPINES ONLY


Job Description

Position Description

- Provide support by reviewing, researching, investigating, auditing
- Provide feedback to team members on audit results
- Analyze and identify trends and provides feedback and reports to reduce errors and improve processes and performance
- Responsible for all aspects of quality assurance
- Create, maintain and track reports in relation to performance
- Serve as subject matter resource to team members, supervisors and management staff

The primary responsibility of this position is the intake and processing and determinations of inpatient and outpatient services according to Plan policy and procedure. The Prior Authorization Nurse performs review of prior authorization requests to determine medical necessity and appropriateness of services following an evaluation of established guidelines. He/she reviews clinical records for determination of appropriateness of services and will engage in telephonic discussion with health care providers and members to explain benefit coverage determinations and to obtain additional clinical information.

- Candidate must possess at least a Bachelor's/College Degree in Nursing with active USRN license.
- Healthcare experience desired but not required
- Calling/Claims processing experience is an added advantage
- Good oral and written communication skill

Skills: management