job description
Are you a Philippine-licensed Registered Nurse (USRN preferred) with expertise in InterQual or MCG criteria and a passion for leading clinical teams? Omega Healthcare Management Services Inc. is seeking a dynamic USRN Team Lead - Quality Control Analyst to join our growing team in a remote, work-from-home capacity based in Bali, Indonesia.
In this pivotal role, you will oversee a high-performing clinical team focused on utilization review, denials management, and appeals processes for US-based healthcare clients. You’ll leverage your deep understanding of medical necessity criteria, clinical documentation, and healthcare regulations to drive quality outcomes while working in a fast-paced, collaborative BPO environment.
As a leader, you’ll mentor junior nurses, ensure adherence to InterQual/MCG guidelines, and optimize workflows to reduce denials and improve client satisfaction. This is an exceptional opportunity for a detail-oriented, analytical nurse leader to make a tangible impact in healthcare quality while enjoying the flexibility of remote work in Bali’s vibrant communities (Canggu, Ubud, Denpasar, Jimbaran, Nusa Dua, Kuta, or Badung).
Omega Healthcare is a global leader in healthcare outsourcing, committed to delivering excellence in clinical services, innovation, and employee growth. Join us and be part of a team that values professional development, work-life balance, and cutting-edge healthcare solutions.
Responsibility
- Lead and mentor a team of clinical reviewers in utilization review, denials management, and appeals processes for US healthcare clients.
- Ensure accurate application of InterQual/MCG criteria and medical necessity guidelines in all case reviews.
- Collaborate with cross-functional teams to reduce denials, improve documentation quality, and enhance client satisfaction.
- Conduct audits and quality assurance checks to maintain compliance with healthcare regulations and company standards.
- Provide clinical expertise and training to team members on best practices for case reviews and appeals.
- Analyze trends in denials and appeals to identify opportunities for process improvements and efficiency gains.
- Serve as a liaison between clinical teams and US-based clients, ensuring clear communication and alignment on quality metrics.
- Stay updated on healthcare regulations, industry trends, and changes to InterQual/MCG criteria to ensure compliance and accuracy.
Qualifications
- Active Philippine RN license (USRN certification is highly preferred).
- Minimum of 3 years of clinical experience in a hospital, utilization review, or case management setting.
- Proven experience with InterQual or MCG criteria and medical necessity reviews.
- Strong leadership skills with 1+ year of team management experience (preferred).
- Excellent analytical, critical thinking, and problem-solving skills with a keen eye for detail.
- Exceptional written and verbal communication skills in English, with the ability to articulate clinical decisions clearly.
- Familiarity with US healthcare systems, denials management, and appeals processes (preferred).
- Ability to work independently in a remote setting with a high degree of self-motivation and time management.
- Proficiency in Microsoft Office Suite (Excel, Word, Outlook) and experience with electronic health record (EHR) systems.