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Clinical Denials
2 weeks ago
Discover your 100% YOU with MicroSourcing
Position: Clinical Denials & Appeals QA Specialist
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 (for you and at least one dependent), 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 Clinical Denials & Appeals QA Specialist, you will:
- Support the QA program build by identifying key audit areas, critical workflow aspects, and automation opportunities to enhance efficiency.
- Monitor performance metrics, including productivity and accuracy, for all Clinical Denials & Appeals staff.
- Escalate production or QA concerns to management and collaborate with Training teams to ensure progress and consistency.
- Demonstrate strong knowledge of production workflows, quality processes, and documentation standards in medical diagnoses and treatment practices.
- Conduct QA audits, maintain detailed QA records, and provide constructive feedback to team members.
- Mentor staff to improve performance, engagement, and job satisfaction.
- Review reports on production and accuracy, offering actionable insights and coaching for continuous improvement.
- Collaborate with Operations, Training, and HR to align onboarding, performance metrics, and training outcomes.
- Participate in client calibration calls, internal audits, and process reviews, representing QA achievements and performance trends.
What You Need
Non-negotiables
- At least 1 year of experience in QA or auditing for clinical appeals writing within a BPO or healthcare setting.
- 3-5 years of acute care clinical experience in a hospital setting (Med/Surg or similar preferred); 2-3 years if ICU experience.
- Bachelor of Science in Nursing.
- Registered Nurse (PHRN or USRN) with active license.
- Proficiency with InterQual or MCG clinical guidelines.
- Broad knowledge of U.S. Government Programs and Insurance Regulations.
- Experience with electronic medical records (EMR) such as Epic, Cerner, or Meditech.
Preferred skills/expertise
- Master's degree or credential in business, healthcare, or related field.
- Certification in case management, clinical appeals, or clinical denials.
- Proficiency with tools for tracking denials and appeals.
- Advanced Microsoft Office Suite skills (Excel, Word, PowerPoint, Outlook, SharePoint).
- Strong analytical, critical thinking, and communication skills.
- Excellent attention to detail, independence in decision-making, and ability to coach and mentor others.
- Experience working in a matrixed environment and presenting QA insights to clients and stakeholders.
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 are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.
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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