Quality Auditor (Clinical Reviewer/Utilization Review Nurse- USRN)
Quality Auditor (Clinical Reviewer/Utilization Review Nurse - USRN)
Job Type: Full-Time (Hybrid: 3x onsite / 2x WFH)Location: Ayala, Makati
Schedule: Morning Shift
About the Role
We are looking for a detail-oriented Quality Auditor/Clinical Reviewer (USRN) to support a U.S.-based healthcare organization.
This role is responsible for evaluating medical records, performing clinical documentation reviews, handling pre-authorization requests, coordinating with payers, and ensuring compliance with healthcare guidelines and quality standards.
The ideal candidate has strong experience in utilization review, case management, or prior authorization, with a deep understanding of U.S. healthcare processes.
Key Responsibilities
Quality Assurance & Chart Review- Conduct medical record reviews to identify documentation gaps, risk areas, and compliance issues
- Perform internal quality assurance audits on nursing documentation
- Identify potential survey risks and regulatory violations
- Review MDS-related documentation for accuracy and completeness
- Flag potential billing and coding discrepancies (Medicare/Medicaid focus)
- Assist in identifying areas of clinical risk and recommend corrective actions
- Support risk management initiatives and quality improvement projects
- Review incident reports and analyze documentation trends
- Ensure alignment with CMS, state, and facility-level regulatory requirements
- Prepare QA summaries and reports for U.S. leadership
- Highly detail-oriented and compliance-focused
- Strong understanding of U.S. Skilled Nursing documentation standards
- Comfortable identifying deficiencies and recommending improvements
- Independent worker with strong critical thinking skills
- Professional and confident communicating with U.S.-based leadership
- Must strictly follow SOPs and compliance workflows
- Experience supporting multiple facilities or projects is a plus
- US Registered Nurse (USRN) license – (Active/Expired) Required
- Minimum 7+ years of clinical nursing experience
- Experience in Utilization Review, Clinical Review, Case Management, or Prior Authorization
- Strong knowledge of clinical documentation review and payer processes
- Familiarity with InterQual, MCG, or similar guidelines
- Excellent analytical, clinical judgment, and documentation skills
- Strong written and verbal communication skills
- Experience working with U.S. healthcare insurance providers or managed care organizations
- Previous remote healthcare operations experience
Compensation
Salary: Competitive
Benefits
Health insurance- Life insurance
- Pay raise opportunities
- Hybrid work setup
- 8-hour shift
- Monday to Friday
- Night shift
- 13th month salary
- Performance bonus
Ready to grow with us?
Send your resume to [email protected] to get your application started