Healthcare Quality Analyst (Utilization Management)

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

COMPANY OVERVIEW:

ImageNet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. ImageNet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers. 

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers.  The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually.  The company has also developed an innovative workflow technology platform, Jetstream TM, to help with traceability, governance and automation of claims operations for its clients.

ImageNet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.