Quality Analyst (Clinical Claims)

Sutherland
Philippines
Workplace: OnsiteFull timeFunction: Quality & Regulatory (Non-Software)Experience: 2+ yearsSkills: ["Analytical","Coaching","Communication","Root cause analysis","Independent work"]

Monitor and audit clinical claim reviews within an AO Clinical Claim Program to ensure documentation accuracy, compliance, and consistency with client and regulatory standards. Maintain quality scorecards, analyze trends and root causes, and deliver reports to operations leaders. Coach and feedback clinical claims associates and nurses, support calibrations, and collaborate with operations, training, and clinical teams to drive corrective actions and continuous quality improvement. Escalate critical quality and compliance issues as needed.

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FursaFursa
Sutherland
Sutherland
23 hours ago

Quality Analyst (Clinical Claims)

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Last checked: 8 hours agoStatus: Live

Job Summary

Monitor and audit clinical claim reviews within an AO Clinical Claim Program to ensure documentation accuracy, compliance, and consistency with client and regulatory standards. Maintain quality scorecards, analyze trends and root causes, and deliver reports to operations leaders. Coach and feedback clinical claims associates and nurses, support calibrations, and collaborate with operations, training, and clinical teams to drive corrective actions and continuous quality improvement. Escalate critical quality and compliance issues as needed.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Quality & Regulatory (Non-Software)
Seniority: Mid level

Key Responsibilities

  • •Conduct regular audits of clinical claim reviews and related transactions to evaluate adherence to guidelines, procedures, and quality standards.
  • •Maintain quality scorecards and audit documentation; analyze quality trends, root causes, and performance gaps.
  • •Prepare and present quality reports to Operations leaders and stakeholders, and recommend corrective/preventive actions.
  • •Provide timely, constructive feedback to Clinical Claims Associates and Nurses; partner with Team Managers on performance improvement plans and support calibration sessions.
  • •Ensure compliance with HIPAA, client policies, applicable healthcare regulations, and internal standards; participate in process improvement initiatives and escalate critical issues.

Key Requirements

  • •Active and unrestricted US Registered Nurse (USRN) license.
  • •Minimum 2 years of recent clinical experience in hospital, utilization management, case management, disability, health insurance, or related settings.
  • •At least 1 year of Quality Analyst experience in a BPO, healthcare, insurance, claims, or clinical operations environment.
  • •Strong understanding of healthcare documentation, claim review processes, and medical terminology.
  • •Knowledge of quality methodologies, auditing principles, and root cause analysis.
Experience:2+ yearsHealthcareInsuranceClaimsClinical operationsBPO
Skills:AnalyticalCoachingCommunicationRoot cause analysisIndependent work
Licenses:US Registered Nurse (USRN) license
Certifications:Lean Six Sigma Yellow Belt
Languages:English
Tech Stack:Microsoft OfficeExcelPowerPoint

Company Brief

Sutherland
Global digital transformation and business process services firm offering AI, automation, cloud engineering, analytics and customer experience solutions to enterprises across industries.
Industry: Professional Services
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Established Company
Funding: Private Equity Backed
Headquarters: Pittsford (Rochester), NY, United States
Founded: 1986
Glassdoor
Glassdoor: 3.5
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