USRN Quality Assurance Specialist

6 days ago


Quezon City, National Capital Region, Philippines PROTALENTNEXUS CONSULTING Full time

USRN Quality Assurance Specialist

On-site | Bridgetowne, Quezon City

Night Shift

Start Date: December 31, 2025 / ASAP

Salary Range: ₱60,000 – ₱90,000

About the Role

We are seeking a highly skilled USRN Quality Assurance Specialist to support the accuracy, compliance, and performance standards of our Medicare Part C Appeals operations. This role ensures alignment with CMS regulatory requirements while providing coaching and quality insights that elevate team performance.

Qualifications

Education & Licensure

Bachelor's Degree in Nursing

Active and valid USRN license (Massachusetts)

Experience

Minimum 1 year experience in Appeals & Grievances (Medicare Part C Appeals focus)

1–2 years experience as a Quality Assurance Specialist/Evaluator in a clinical BPO or CPO setting

1 year InterQual experience (Medicare & Medicaid)

Experience supporting CMS Program Audits and Client Audits

Prior experience mentoring and coaching new QA staff

Technical & Regulatory Knowledge

Strong understanding of CMS Medicare Part C Appeals regulatory standards

In depth knowledge of clinical terminology, medical necessity review principles, and health insurance operations

Proficiency with Quality Audit Systems and Microsoft Office Suite

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

Soft Skills

Excellent verbal and written communication skills

Strong analytical, critical thinking, and problem solving abilities

Collaborative mindset with effective coaching and communication abilities

Other Requirements

Willing to work onsite with flexible schedules, including US hours and holidays



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