Clinical Review Specialist

NTT
Philippines
Workplace: OnsiteFull timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 1-3 yearsSkills: ["Communication","Reading comprehension","Writing skills","Independent work","Analytic skills"]

Conduct clinical reviews to resolve and process appeals by examining medical records and clinical data to determine medical necessity. Prepare case reviews for Medical Directors, ensure timely appeal handling aligned with State, Federal, and NCQA standards, and communicate with providers and facilities. Create resolution communications and reports, recommend approval/denial or medical review presentations, and partner with teams to improve appeals processes and prevent recurrences.

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FursaFursa
NTT
NTT
1 week ago

Clinical Review Specialist

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Last checked: 4 hours agoStatus: Live

Job Summary

Conduct clinical reviews to resolve and process appeals by examining medical records and clinical data to determine medical necessity. Prepare case reviews for Medical Directors, ensure timely appeal handling aligned with State, Federal, and NCQA standards, and communicate with providers and facilities. Create resolution communications and reports, recommend approval/denial or medical review presentations, and partner with teams to improve appeals processes and prevent recurrences.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Review medical records and clinical data to determine medical necessity and resolve appeals according to policies, guidelines, and NCQA standards.
  • •Prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing the basis for the appeal.
  • •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 generate resolution communications and reporting.
  • •Maintain appeal files and recommend approvals/denials or prepare case recommendations for medical review as necessary.

Key Requirements

  • •1-3 years of experience in processing appeals or utilization management.
  • •RN (Registered Nurse) with State required Licensure and/or Compact State Licensure.
  • •Knowledge of utilization management processes.
  • •Knowledge of NCQA and Medicaid regulations.
  • •Strong reading comprehension and writing skills, analytic abilities, and ability to work independently.
Experience:1-3 yearsUtilization managementAppeals processing
Skills:CommunicationReading comprehensionWriting skillsIndependent workAnalytic skills
Licenses:RN

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