{"id":2772492,"url":"https://alion.io/job/ust-utilization-management-qa-analyst-usrn-license-required","title":"Utilization Management QA Analyst (USRN License Required)","company":{"id":1774626,"name":"UST","domain":"ust.com","url":"https://alion.io/company/ust-com","size_band":"5000+","is_staffing_agency":false,"employer_type":"direct","is_intermediary":false,"listed_via":null,"ats_vendor":"RippleHire","truth_index":null},"role":"QA","role_family":"QA","seniority":"senior","employment_type":null,"work_mode":"on_site","remote_scope":null,"remote_scope_basis":null,"remote_working_hours":null,"hiring_geo_confidence":"structured","locations":["Taguig, Philippines"],"countries":["PH"],"hiring_countries":[],"hiring_countries_total":0,"salary":null,"salary_estimate":{"min_usd":13500,"max_usd":38000,"period":"year","method":"global_role_cell_scaled_by_country","sample_n":1081},"experience_years_min":5,"visa_sponsorship":false,"relocation_package":false,"has_equity":false,"technologies":[{"name":"Microsoft Office","optional":true},{"name":"Outlook","optional":true}],"status":"live","first_seen_at":"2026-09-07T00:00:00Z","employer_posted_date":"2026-10-17","last_verified_at":"2026-10-18T12:31:07Z","board_verified":true,"closed_at":null,"days_open":41,"trust":{"level":"ok","repost_count":null,"flags":[],"days_open":41},"description":"Job Description: Utilization Management (UM) Quality Assurance Nurse\nJob Summary\nThe Utilization Management (UM) Quality Assurance Nurse is responsible for supporting quality improvement initiatives by conducting comprehensive audits, analyzing operational processes, identifying trends and opportunities for improvement, and ensuring compliance with utilization management policies and procedures. This role plays a critical part in maintaining the accuracy, consistency, and quality of UM reviews, documentation, and member interactions while supporting operational excellence and regulatory compliance.\nThe QA Nurse collaborates with leadership and operations teams to evaluate performance, provide actionable insights, develop educational materials, support system implementations, and contribute to continuous process improvement initiatives.\nKey Responsibilities\nQuality Assurance & Auditing\nPerform quality assurance audits on completed prospective, concurrent, and retrospective utilization management clinical reviews involving inpatient, outpatient, ambulatory, and ancillary services.Evaluate accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes.Conduct clinical quality and operational audits to ensure adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards.Evaluate UM clinical decision-making against MCG, CMS, regulatory, policy, and contractual requirements.Identify, document, and communicate audit findings, root cause, trends, risks, and opportunities for process improvement.Analyze audit results and trends to identify recurring issues, potential root causes, and opportunities for corrective or performance improvement activitiesMaintain and support the development of UM audit tools, methodologies, scoring standards, and related quality documentation\nSupport regulatory compliance through quality audit, data analysis, documentation review, and identification of potential compliance risks.\nAnalysis & Reporting\nAssist in monitoring quality initiatives, outcomes, metrics, and objectives to ensure performance goals are achieved.\nPrepare reports, presentations, and other materials as needed to communicate audit results and recommendations to management.\nSupport root cause analysis activities and recommend corrective and preventive actions.\nEducation & Training\nSupport UM leadership in providing targeted education, audit feedback, and clinical coaching to UM staff based on identified quality findings and trends\nProvides recommendation related to, but not limited to, the following:","description_format":"text","description_chars":2611,"description_truncated":false,"requirements":{"experience_years_min":5,"management_years_min":null,"team_size_min":null,"manages_managers":false,"education":{"level":"bachelor","optional":true},"security_clearance":false,"languages":[]},"benefits":[],"hiring_locations":[],"hiring_excludes":[],"relocation_offered":false,"industries":["IT Consulting & Digital Transformation","IT Outsourcing & Dedicated Teams"],"lifecycle":[{"event":"open","at":"2026-10-17T06:49:13Z"}],"visa":[],"liveness":{"score":14,"band":"cold","label":"Long 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