Healthcare Quality Analyst (Utilization Management)

Job description

Healthcare Quality Analyst (Utilization Management) Work Set-up: Onsite - Potential to WFH after training Location: Valero , Makati City Schedule: Graveyard | Shifting Hours Position Summary The Healthcare Quality Analyst (Utilization Management) is responsible for monitoring, evaluating, and improving the quality and accuracy of administrative utilization management activities performed by the UM Operations team. This role conducts quality audits, identifies performance trends, provides coaching feedback, and supports continuous process improvement initiatives to ensure compliance with client policies, regulatory requirements, service level agreements (SLAs), and internal quality standards. The Quality Analyst partners closely with Operations Supervisors, Trainers, and Leadership to promote operational excellence through consistent quality monitoring and performance analysis. This is a non-clinical position . The Quality Analyst does not perform medical necessity reviews, make clinical determinations, approve or deny services, or perform duties requiring clinical licensure. Essential Duties & Responsibilities Quality Monitoring & Auditing Conduct quality audits of completed authorization, referral, fax intake, and documentation activities. Evaluate work against established quality standards, client SOPs, and business rules. Verify documentation accuracy, completeness, and compliance. Identify processing errors, documentation deficiencies, and workflow gaps. Ensure HIPAA, CMS, NCQA, URAC, and client requirements are consistently met. Performance Evaluation Score quality audits using approved audit tools. Provide clear and objective written feedback. Identify recurring trends and root causes. Monitor individual and team quality performance. Recommend corrective actions to improve performance. Coaching & Continuous Improvement Deliver quality feedback sessions with Operations Supervisors. Partner with Training to identify knowledge gaps. Assist with calibration sessions to ensure scoring consistency. Participate in process improvement initiatives. Recommend updates to quality guidelines when appropriate. Reporting & Analytics Prepare daily, weekly, and monthly quality reports. Analyze quality trends and defect rates. Track audit completion and quality KPIs. Present findings to Operations leadership. Support internal and external audit readiness. Documentation & Compliance Maintain complete audit documentation. Ensure confidentiality of Protected Health Information (PHI). Maintain accurate audit records for compliance purposes. Operational Support Participate in policy and workflow updates. Assist in creating quality reference materials. Support new process implementation. Perform additional quality-related duties as assigned. Required Qualifications High School Diploma required; Associate's or Bachelor's degree preferred. Minimum of 2–3 years of experience in healthcare operations, prior authorization, utilization management, claims, provider services, or healthcare administration. Minimum of 1 year of Quality Assurance or auditing experience preferred. Strong knowledge of healthcare documentation standards. Knowledge of medical terminology. Excellent written and verbal communication skills. Strong analytical and organizational skills. Intermediate Microsoft Office proficiency. Preferred Experience Experience with: Utilization Management Prior Authorization Referral Management Fax Intake Medical Records Provider Services Managed Care Medicare Advantage Medicaid Commercial Health Plans Quality Assurance Root Cause Analysis Work Arrangement: This is a full-time position that requires reporting to the office with a possibility of remote work set-up after successful completion of training. However, please note that this is a performance-based role, and the company reserves the right to require employees to report onsite at any time based on business needs, performance evaluations, operational requirements. Flexibility to transition to an office-based setup when necessary is expected. Additional Benefits: Comprehensive HMO Coverage - Medical & Dental HMO coverage on Day 1 plus 1 dependent About Imagenet Imagenet is a technology-forward healthcare operations partner with more than 25 years of experience helping healthcare payers manage critical administrative and operational processes. Founded in 2000 and headquartered in Tampa, Florida, Imagenet supports 150+ health plans through its payer clients. Our teams help improve efficiency, accuracy, visibility, and service across complex healthcare operations, including digital mailroom, claims adjudication, contact center, member communications, and related administrative functions. By combining experienced operational teams, proven processes, and purpose-built workflow technology, Imagenet helps payers keep essential processes moving for the members, providers, and communities they serve. Imagenet operates 10 secure facilities across the U.S. and one secure facility in Manila, Philippines. Joining Imagenet means contributing to work that supports the healthcare operations members and providers rely on every day.