Healthcare Quality Auditor | Provider Services

Healthcare Quality Auditor | Provider Services

Work Set-up: Onsite - eligible to WFH after training based on performance and business requirements

Location: Valero, Makati City
Schedule: Graveyard | Shifting Hours

Job Summary

The Healthcare Quality Auditor - Provider Services is responsible for reviewing, evaluating, and scoring healthcare provider-service interactions and related documentation to ensure accuracy, compliance, process adherence, and consistent provider experience. This role supports quality assurance across inquiries related to eligibility, claims, payments, appeals, Explanation of Benefits (EOBs), provider dispute resolution, and other provider-facing workflows.

The Quality Auditor is accountable for completing assigned audits accurately and timely, applying approved QA rubrics consistently, identifying error trends, documenting findings clearly, participating in calibration and Audit the Auditor activities, completing assigned production work when required, and providing actionable feedback that helps improve quality, compliance, documentation, and provider-service outcomes.

This role partners closely with Operations, Team Leaders, Training, Workforce Management, Compliance, and other support teams to reinforce a Zero Error Mindset, strengthen audit consistency, reduce repeat errors, and support sustained performance improvement across the account.

Key Responsibilities

Quality Audit Execution & Review Management

• Complete assigned quality audits for provider-service interactions, claims-related transactions, documentation, and other designated work types within established audit volume, sampling, quality, and turnaround-time requirements.


• Complete actual production work, including taking calls when assigned, and achieving the required production volume and cadence expectations.


• Apply approved QA scorecards, audit forms, client requirements, standard operating procedures, and scoring guidelines consistently and objectively.


• Review work for data accuracy, policy accuracy, financial or claims-impact accuracy, documentation quality, compliance adherence, call-handling standards, and timely resolution.


• Audit provider-service inquiries across applicable channels, including phone, email, fax, web inquiries, and other designated communication channels.


• Validate that Advocates use approved resources, follow proper workflows, document interactions completely, and provide accurate provider-facing information.


• Identify critical errors, repeat errors, compliance risks, documentation gaps, process misses, and provider-experience concerns requiring immediate escalation.


• Maintain accurate audit records and ensure all audit results are entered, stored, and reported in the designated QA platform or reporting tracker.


• Complete required audits within established timelines while maintaining accurate audit documentation and adherence to required sampling expectations.

Audit Accuracy, Calibration & Consistency

• Maintain consistent and objective application of QA standards across all audits and work types.


• Participate in internal QA calibrations, client calibrations, audit-the-auditor reviews, and side-by-side scoring sessions to ensure scoring alignment.


• Meet audit accuracy expectations and maintain acceptable audit-the-auditor results through consistent scoring alignment.


• Demonstrate strong understanding of audit definitions, error severity, critical error criteria, scoring methodology, and account-specific quality expectations.


• Review calibration outcomes, incorporate feedback, and adjust scoring practices to maintain alignment with internal and client standards.


• Participate in calibration and Audit the Auditor activities and demonstrate sustained scoring alignment with internal, client, and account-specific requirements.


• Escalate unclear scoring scenarios, conflicting procedures, or policy interpretation issues to QA leadership, Operations, Training, or Compliance as appropriate.


• Support a Zero Error Mindset by helping frontline teams understand preventable errors and the behaviors required to avoid recurrence.

Feedback, Disputes & Error Resolution

• Provide timely, clear, specific, and constructive audit feedback to Advocates, Team Leaders, and Operations partners in accordance with established timelines.


• Ensure feedback includes the error identified, supporting evidence, applicable guideline or policy reference, impact, and expected corrective action.


• Support the quality dispute process by reviewing submitted disputes objectively, validating supporting documentation, and responding within required turnaround times.


• Partner with Team Leaders to ensure coaching is aligned to audit findings, repeat-error trends, and account for expectations.


• Complete root-cause analysis and corrective-action follow-up for recurring, preventable, critical, or high-impact quality errors.


• Identify potential knowledge gaps, training needs, unclear procedures, or system issues contributing to quality defects.


• Recommend refresher training, huddles, job aids, PKTs, boot camps, or process clarification based on audit findings and trend analysis.


• Immediately escalate critical errors, compliance concerns, or situations that may result in incorrect information being provided to a provider or improper handling of protected information.


• Identify quality issues early and escalate risks before they become client-reported errors.

QA Reporting, Trend Analysis & KPI Support

• Track completed audits against assigned daily, weekly, and monthly audit goals, including volume, timeliness, scoring accuracy, and documentation completeness.


• Prepare or support QA reporting that includes total audits completed, QA scores, error categories, repeat errors, critical errors, risk items, dispute outcomes, and coaching completion visibility.


• Complete timely and accurate daily, weekly, and monthly QA reporting in accordance with internal, client, and account requirements.


• Identify, document, and trend recurring and preventable errors across individual, team, process, training, system, and compliance categories.


• Share actionable insights with QA leadership, Operations, Training, Team Leaders, and other stakeholders to support performance improvement.


• Support reduction of repeat errors within supported teams by sharing trend insights, corrective-action themes, and recommended prevention actions.


• Support weekly, monthly, quarterly, or client-facing business reviews by providing quality findings, trend summaries, root-cause themes, and recommended actions.


• Understand that audit volume, QA targets, sampling methodology, reporting cadence, and scorecard requirements may be updated based on client requirements, operational needs, or changes to scope of work.

Training, Knowledge Management & Process Support

• Support new-hire certification, nesting, production-readiness, and post-training quality validation by completing assigned audits and sharing audit findings with Training and Operations.


• Review training outcomes, PKT results, early-production QA results, and recurring error trends to help identify knowledge gaps and development needs.


• Provide input into job aids, refresher sessions, calibration materials, audit guidelines, and process clarifications based on audit observations.


• Maintain strong working knowledge of client requirements, process updates, system changes, SOPs, scorecards, and provider-service workflows.


• Maintain knowledge of Imagenet's Account QA Framework and client-specific requirements and apply those standards consistently in audits, feedback, reporting, and process-support activities.


• Help reinforce consistent understanding of quality standards across frontline employees, Team Leaders, Training, and Operations.

Provider Experience & Documentation Quality

• Evaluate provider-facing communication for professionalism, empathy, active listening, appropriate probing, confidence, clarity, and resolution focus.


• Validate that Advocates provide accurate explanations related to eligibility, benefits, claims status, payment, denial reasons, appeals, EOBs, and other provider inquiries.


• Review interaction notes and system documentation for completeness, accuracy, audit readiness, and alignment with approved documentation standards.


• Identify avoidable transfers, incomplete research, unresolved inquiries, poor documentation, or communication behaviors that may negatively affect provider experience.


• Model the quality standards being evaluated by maintaining 100% quality on any production work completed, including provider calls or other assigned frontline work.

Qualifications

• High school diploma or equivalent required; college degree or relevant post-secondary education is preferred.


• At least 4 to 5 years of experience in a healthcare contact center, provider services, claims support, claims processing, quality assurance, or comparable healthcare operations environment.


• Prior experience of 2-3 years as a Quality Auditor, QA-Analyst, SME.


• Working knowledge of healthcare claims, EOBs, appeals, eligibility, benefits, payment processes, provider-service workflows, documentation standards, and contact-center operations.


• Demonstrated ability to interpret QA guidelines, identify errors, apply scoring criteria consistently, and provide clear rationale for audit findings.


• Strong analytical, problem-solving, decision-making, organizational, verbal, and written communication skills.


• Exceptional attention to detail and demonstrated commitment to quality, accuracy, compliance, confidentiality, and customer/provider experience.


• Ability to work in a metric-driven environment and meet audit volume, audit quality, feedback timeliness, calibration, reporting, attendance, adherence, and compliance requirements.


• Proficiency with Microsoft Office and online systems; ability to learn and navigate multiple healthcare, client, QA, reporting, workforce, and performance-management systems.


• Experience with Monday.com, AWS Connect, QA platforms, call-recording tools, claims systems, workforce tools, and performance dashboards is highly preferred.


• Ability to work flexible schedules, including nights, weekends, and holidays, based on client coverage and quality requirements.

Performance Accountability

Quality Auditors are accountable for completing audits accurately, objectively, consistently, and within established timelines regardless of work location. Quality Analysts are expected to model the quality standards they are responsible for evaluating and are held to a 100% quality expectation on any production work completed. Errors identified in QA production will be reviewed, trended, and addressed through the same accountability processes applied to the employees they support. Remote or hybrid work is contingent upon sustained audit productivity, audit accuracy, calibration alignment, responsiveness, documentation quality, confidentiality, and compliance with all applicable requirements. Failure to meet established QA expectations may result in coaching, retraining, performance management, return to onsite work, or other appropriate action in accordance with company policy.

Work Arrangement & Remote Work Eligibility:

This position may require onsite presence during training, transition, new-hire nesting, team stabilization, client visits, performance-management activities, or other operational needs.

Quality Auditors may be eligible for a remote or hybrid work arrangement, subject to sustained audit performance, calibration accuracy, productivity, attendance, responsiveness, security, technology, client, and business requirements.

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, JetStreamTM, 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.