The Clinical Transactional Quality Manager is responsible for overseeing and strengthening clinical audit programs to ensure accuracy, compliance, and consistency across healthcare operations. This role leads transactional quality governance, audit execution, and inter-rater reliability, while partnering closely with Operations, Training, and Clinical Practice teams to address quality gaps and mitigate risk. The TQ Manager ensures adherence to regulatory, accreditation, and client requirements (e.g., HIPAA, NCQA, URAC, ISO) and plays a critical role in safeguarding clinical integrity, patient safety, and client satisfaction through robust quality systems and team leadership.Business Excellence - Quality Manager

Education

• Bachelor’s degree in Nursing (PHRN required; USRN preferred).

• Certifications or formal training in Quality Management, NCQA/URAC, COPC, ISO, or Clinical Auditing are an advantage.

Experience

• At least 2 years of experience in clinical operations, clinical quality, or clinical training, with exposure to transactional quality, utilization management, case management, or payer-based healthcare processes.

• Minimum of 2 years in a supervisory role or at least 1 year in a lead or associate managerial role, overseeing clinical staff, quality analysts, auditors, or trainers.

• Demonstrated experience or exposure in quality audits, decision accuracy, documentation review, coaching, or compliance activities within healthcare services.

• Familiarity with regulatory and accreditation requirements (e.g., HIPAA, NCQA, URAC, ISO) is strongly preferred.

Mandatory Skills & Competencies

• Strong clinical judgment and understanding of payer-based healthcare workflows.

• Proficiency in transactional quality frameworks, audit methodologies, and root-cause analysis.

• Ability to implement and sustain Quality and Information Security Management Systems (QISMS).

• Knowledge of HIPAA, PHI handling, and incident reporting protocols.

• Ability to establish controls and safeguards for confidential and sensitive clinical information.

• Strong stakeholder management, communication, and coaching skills.

Roles & Responsibilities

Clinical Transactional Quality & Governance

• Lead and manage transactional quality programs across clinical operations (e.g., UM, CM, Prior Authorization, Appeals).

• Define, implement, and maintain clinical audit frameworks, scoring rubrics, and sampling methodologies.

• Ensure compliance with client SLAs, contractual quality metrics, and accreditation standards.

• Analyze audit trends to identify systemic risks impacting accuracy, safety, and compliance.

• Lead inter-rater reliability (IRR) calibration sessions to ensure scoring consistency and audit integrity.

• Review and approve audit outcomes, escalations, and quality determinations.

• Conduct and lead investigations of critical errors, high-risk findings, and regulatory deviations.

• Serve as the primary quality liaison for client discussions related to transactional quality performance.

People Management & Capability Building

• Lead, coach, and develop Quality Associate Managers, Quality Team Leads and clinical auditors.

• Drive auditor readiness through structured onboarding, calibration, and ongoing coaching.

• Manage performance, engagement, and workload distribution within the quality team.

• Partner with Operations and Training to address resistance to audit findings using data-driven, clinical discussions.

• Support resolution of quality-related grievances in collaboration with Business Excellence leadership.

Audit Execution & Quality Systems

• Plan and conduct internal quality audits and support client-initiated audits and inspections.

• Enforce compliance with internal SOPs, clinical guidelines, and quality standards.

• Track corrective and preventive actions (CAPA) and ensure timely closure of quality findings.

• Coordinate and host client audits, regulatory reviews, and accreditation inspections.

• Maintain audit documentation, evidence repositories, and governance artifacts.

Process Improvement & Cross-Functional Collaboration

• Partner with Continuous Improvement (CI) teams to translate audit findings into targeted improvement initiatives.

• Provide clinical quality input to process changes to ensure patient safety and regulatory compliance.

• Support standardization of workflows and adoption of best practices across clinical programs.

Documentation, Training & Compliance

• Review and approve clinical SOPs, audit tools, job aids, and quality documentation.

• Ensure all documentation is controlled, versioned, and compliant with ISO and internal standards.

• Coordinate and support quality and audit training for Operations and Training teams.

• Ensure completion of mandatory HIPAA, compliance, and quality training across assigned teams.

• Maintain training records and quality documentation databases.

General Safety, Security & Regulatory Compliance

• Uphold Quality Information Security Management System (QISMS) principles to protect organizational and client assets.

• Ensure confidentiality, integrity, and availability of clinical and operational information.

• Maintain compliance with HIPAA, NCQA, URAC, ISO, and applicable healthcare regulations.

Quezon City, Bridgetowne ZetaPhilippines