Clinical Review Specialist

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

Perform clinical reviews for appeals by examining medical records and clinical data to determine medical necessity in line with company policies and NCQA standards. Prepare case reviews for Medical Directors, ensure timely appeal processing and responses, and coordinate with providers, facilities, and internal teams. Generate member/provider communications and reporting, maintain appeal files, and recommend approvals or denials for claim reconsiderations, including support for process improvements.

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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

Perform clinical reviews for appeals by examining medical records and clinical data to determine medical necessity in line with company policies and NCQA standards. Prepare case reviews for Medical Directors, ensure timely appeal processing and responses, and coordinate with providers, facilities, and internal teams. Generate member/provider communications and reporting, maintain appeal files, and recommend approvals or denials for claim reconsiderations, including support for process improvements.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Review appeal cases by researching the appeal, applying criteria, and analyzing the basis to determine medical necessity.
  • •Prepare case reviews and recommendations for Medical Directors, including approvals/denials for reconsideration and medical review presentations.
  • •Ensure timely review, processing, and response to appeals according to State, Federal, and NCQA standards.
  • •Communicate with providers, facilities, and internal departments regarding appeal requests and generate member/provider resolution communications and reporting.
  • •Maintain files on individual appeals and partner with leadership and teams to improve consistency, efficiency, and appropriateness to prevent recurrences.

Key Requirements

  • •1–3 years of experience processing appeals or utilization management.
  • •RN—Registered Nurse—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, with good communication and analytic abilities.
Experience:1-3 years
Skills:CommunicationAnalytic skillsIndependent workSound judgementWriting 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