QA Team Lead - Clinical Denials

Work setup: ONSITE / BGC, Taguig within 6 months then transfer to Bridgetowne, QC

Work schedule: Nightshift

The QA Team Lead – Clinical Denials provides day-to-day leadership and oversight for the quality assurance function supporting Clinical Denials operations. The position is responsible for ensuring consistent application of QA standards, audit methodology, quality scorecards, coaching practices, and client-specific requirements.

The QA Team Lead oversees QA activities, monitors quality performance, conducts complex and escalated audits, leads calibration activities, identifies systemic quality issues, and partners with operational leadership to implement corrective and preventive actions.

This role serves as a subject-matter expert and quality resource for Clinical Denials Specialists, Team Leads, Managers, and other revenue cycle stakeholders.

Qualifications

Required

• Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field.
• Active RN license or applicable clinical credential.
• Minimum 4 to 5 years of healthcare experience in clinical denials, CDI, utilization management, coding, RCM, appeals, or related areas.
• Minimum 1 to 2 years of QA, auditing, team leadership, or supervisory experience.
• Strong knowledge of clinical documentation, medical necessity, coding, reimbursement, inpatient DRG, level of care, and payer requirements.
• Demonstrated ability to analyze quality data and identify trends.
• Strong leadership, communication, coaching, and problem-solving skills.
• Excellent attention to detail.

Preferred

• CDAS or equivalent denial management credential.
• CCDS, CDIP, or equivalent CDI certification.
• CCS, CPC, or equivalent coding certification.
• Experience leading clinical denial QA programs.
• Experience developing QA scorecards and audit methodologies.
• Experience with Epic, EHR systems, and payer portals.
• Experience with reporting tools, dashboards, and data analytics.
• Experience supporting multiple clients or large-scale RCM programs.

Duties and Responsibilities

QA Team Leadership

• Leads daily activities of the Clinical Denials QA team.
• Assigns and prioritizes QA audits based on workload, risk, denial type, financial impact, and business requirements.
• Monitors QA productivity, audit completion, accuracy, turnaround time, and quality performance.
• Provides coaching, mentoring, and performance feedback to QA staff.
• Supports onboarding, training, and competency development of QA team members.
• Ensures appropriate coverage and distribution of QA workload.
• Escalates significant performance, quality, compliance, and operational concerns to management.

Quality Audit & Oversight

• Oversees routine, targeted, and focused audits of clinical denial reviews and appeals.
• Conducts complex and high-dollar case audits.
• Reviews escalated or disputed QA findings.
• Ensures audit findings are supported by objective evidence.
• Validates consistent application of QA scorecards and error definitions.
• Monitors adherence to client-specific quality requirements.
• Ensures critical quality and compliance issues are appropriately escalated.
• Reviews trends in clinical, coding, documentation, reimbursement, and appeal quality.

QA Standards & Calibration

• Maintains and updates QA scorecards, audit tools, and quality standards.
• Leads regular calibration sessions for QA staff and operational teams.
• Establishes consistent interpretation of clinical, coding, payer, and quality requirements.
• Identifies areas of disagreement between QA and operations and facilitates resolution.
• Partners with management to establish quality targets and performance expectations.
• Supports development of standardized QA methodologies across clients and programs.

Quality Analytics & Reporting

• Analyzes individual, team, client, payer, and denial-category quality trends.
• Prepares QA dashboards and management reports.
• Identifies recurring error patterns and systemic quality risks.
• Tracks critical error trends and corrective action effectiveness.
• Provides insights into the relationship between quality performance and denial recovery.
• Presents quality findings and recommendations to operational leadership.
• Supports client reporting and business reviews as required.

Coaching & Corrective Action

• Partners with Team Leads and Managers to address quality performance issues.
• Provides actionable feedback based on audit findings.
• Identifies training and competency gaps.
• Develops recommendations for targeted training and remediation.
• Monitors effectiveness of corrective actions.
• Supports performance improvement plans where appropriate.
• Ensures feedback is timely, objective, consistent, and documented.

Denial Prevention & Process Improvement

• Identifies systemic issues contributing to inaccurate or unsuccessful appeals.
• Partners with Clinical Denials, CDI, HIM, Coding, Utilization Management, and RCM leadership to address root causes.
• Recommends workflow, training, documentation, and process improvements.
• Participates in denial prevention initiatives.
• Identifies opportunities to improve appeal quality and denial recovery.
• Supports implementation of standardized best practices across teams and clients.

Compliance & Regulatory Knowledge

• Maintains knowledge of payer policies, reimbursement guidelines, coding principles, clinical documentation requirements, and applicable regulations.
• Ensures QA standards remain aligned with current requirements.
• Identifies potential compliance risks and escalates appropriately.
• Supports internal and client audits as required.
• Maintains confidentiality of patient and client information.

Stakeholder & Client Collaboration

• Partners with Clinical Denials Team Leads and Managers to improve operational quality.
• Participates in client meetings and quality reviews when required.
• Communicates quality trends, risks, and recommendations clearly and professionally.
• Supports client-specific audit requirements.
• Serves as an escalation point for complex or disputed QA findings.