Utilization and Denials Management Auditor

Discover your 100% YOU with MicroSourcing
Position:
Utilization and Denials Management Auditor

Location:
Taguig

Work setup & shift:
Onsite | Night shift

Why join MicroSourcing?
You'll Have

• Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time-off with cash conversion, group life insurance, and performance bonuses
• A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company-sponsored events and activities.
• Work-Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.
• Career Growth: Take advantage of opportunities for continuous learning and career advancement.
• Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.

Your Role
As a Utilization And Denials Management Auditor, You Will
Quality Assurance (QA) & Delivery

• Support the build and execution of the QA program, including identifying critical workflows/accounts to audit and advising on effective audit attributes.
• Monitor performance of Utilization and Denials Management staff using key productivity and accuracy metrics across Utilization Management and Clinical Denials & Appeals.
• Escalate production and QA risks or roadblocks to the Manager and collaborate with Training teams to communicate progress and improvement plans.
• Demonstrate domain expertise in production schedules, quality processes, and clinical documentation of diagnoses and treatment practices.
• Apply a deep understanding of Utilization and Denials Management workflows, guidelines, and QA standards.

QA Administration & Documentation

• Provide training, coaching, and ongoing feedback to team members on quality and performance.
• Maintain and monitor QA records, audit results, and education findings for assigned staff.
• Complete special projects, including full Utilization and Denials Management audits, in a timely manner.
• Mentor staff to maximize performance, engagement, and professional growth.
• Assist in monitoring team morale and job satisfaction.

Performance & Evaluation

• Review production and quality accuracy reports and system dashboards; share actionable feedback with team members and leadership.
• Motivate team members through effective coaching and training to improve quality, professionalism, and consistency.
• Conduct monthly team meetings and participate in annual performance evaluations.

Collaboration & Stakeholder Management

• Partner with global Operations, Training, and HR teams to support onboarding and on-the-job learning (OJL).
• Participate in client calibration calls to align training KPIs with operational metrics.
• Support client visits, internal audits, and process reviews by presenting QA insights, dashboards, and outcomes.
• Perform other duties and responsibilities as assigned.

What You Need
Non-negotiables

• Minimum 1 year of QA or auditing experience in Utilization Management and/or Clinical Denials & Appeals within a healthcare setting.
• 3–5 years of acute care clinical experience in a hospital setting (Med/Surg or similar preferred); 2–3 years if ICU background.
• Bachelor of Science in Nursing.
• Active Registered Nurse (RN) license with PHRN or USRN credentials.
• Proficiency in InterQual or MCG clinical guidelines and strong knowledge of U.S. government programs and insurance regulations.
• Experience with hospital-based EMR systems such as Epic, Cerner, or Meditech.
• Strong verbal and written English communication skills with a minimum CEFR B2 level.

Preferred skills/expertise

• Master's degree or credential in business, healthcare, or a related field preferred.
• Certification in case management, clinical appeals, or clinical denials (ACMA preferred).
• Proficiency in tools used for tracking authorizations, denials, and appeals, as well as the Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint).
• Strong attention to detail with excellent follow-up and follow-through skills.
• Ability to make independent decisions within scope, using sound judgment and discretion.
• Demonstrated analytical and critical thinking skills.
• Experience working in a matrixed environment.
• Strong teamwork, integrity, and professionalism in all interactions.
• Excellent written and verbal communication skills, including the ability to create clear and impactful presentations.

About MicroSourcing
With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines.

Our commitment to 100% YOU
MicroSourcing firmly believes that our company's strength lies in our people's diversity and talent. We foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds.

At MicroSourcing, equality is not merely a slogan – it's our commitment. Our way of life. Here, we don't just accept your unique authentic self – we celebrate it, valuing every individual's contribution to our collective success and growth. Join us in celebrating YOU and your 100%

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