BPO Clinical Review Specialist

NTT
Manila
Full timeFunction: Product ManagementExperience: 1-3 yearsSkills: ["Communication","Reading comprehension","Writing","Analytic skills","Independent work","Sound judgement"]

Conduct clinical reviews for appeals by analyzing member medical records and clinical data to determine medical necessity. Prepare case reviews for medical directors, ensure timely processing and responses aligned with State, Federal, and NCQA standards, and coordinate with providers, facilities, and internal teams. Document appeals and recommend approval/denial or escalation for medical review, helping improve consistency, efficiency, and appropriateness of resolutions for Medicaid and utilization management.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
NTT
NTT
4 days ago

BPO Clinical Review Specialist

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 16 hours agoStatus: Live

Job Summary

Conduct clinical reviews for appeals by analyzing member medical records and clinical data to determine medical necessity. Prepare case reviews for medical directors, ensure timely processing and responses aligned with State, Federal, and NCQA standards, and coordinate with providers, facilities, and internal teams. Document appeals and recommend approval/denial or escalation for medical review, helping improve consistency, efficiency, and appropriateness of resolutions for Medicaid and utilization management.
Location: Manila
Employment Type: Full time
Job Function: Product Management
Seniority: Entry level

Key Responsibilities

  • •Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the appeal basis.
  • •Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
  • •Communicate with providers, facilities, and other departments regarding appeal requests and resolutions.
  • •Generate appeal resolution communication and reporting for members and providers aligned with company policies and NCQA standards.
  • •Maintain appeal files and review claim appeals for reconsideration, recommending approvals/denials or preparing for medical review presentations.

Key Requirements

  • •1-3 years of experience processing appeals or utilization management.
  • •RN license with state-required licensure and/or Compact State licensure.
  • •Knowledge of utilization management processes.
  • •Knowledge of NCQA and Medicaid regulations.
  • •Strong communication with reading comprehension and writing skills, plus analytic skills to work independently.
Experience:1-3 years
Skills:CommunicationReading comprehensionWritingAnalytic skillsIndependent workSound judgement
Licenses:Registered Nurse (RN) state-required licensureCompact State licensure

Company Brief

NTT
Dimension Data, operating under NTT Ltd, provides managed IT services, cloud and data center solutions, networking, cybersecurity, and digital transformation services to enterprise customers worldwide.
Industry: Professional Services
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Established Company
Valuation: Public Company (Market Cap in USD)
Headquarters: London, United Kingdom
Founded: 1983
WebsiteLinkedIn