BPO Clinical Review Senior Specialist

NTT
United States
Workplace: RemoteFull timeUSD 81,120+Function: Solutions Engineering & Sales EngineeringExperience: 3+ yearsSkills: ["Analytical thinking","Problem-solving","Written communication","Verbal communication","Organizational skills"]

Conduct quality audits for clinical appeal reviews and provide subject matter expertise to ensure accurate, timely processing of member and provider appeals. Review medical records and appeal determinations for compliance with organizational policies, regulatory requirements, Medicaid guidelines, and NCQA standards. Partner with operations leadership to identify quality trends, coach teams, support calibration sessions, and recommend process improvements to strengthen consistency and operational effectiveness.

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FursaFursa
NTT
NTT
1 week ago

BPO Clinical Review Senior Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 5 hours agoStatus: Live

Job Summary

Conduct quality audits for clinical appeal reviews and provide subject matter expertise to ensure accurate, timely processing of member and provider appeals. Review medical records and appeal determinations for compliance with organizational policies, regulatory requirements, Medicaid guidelines, and NCQA standards. Partner with operations leadership to identify quality trends, coach teams, support calibration sessions, and recommend process improvements to strengthen consistency and operational effectiveness.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Solutions Engineering & Sales Engineering
Seniority: Mid level

Key Responsibilities

  • •Conduct quality audits of clinical appeals reviews to ensure accuracy, consistency, and compliance with established standards.
  • •Evaluate medical records, clinical documentation, and appeal determinations against medical necessity and utilization management criteria.
  • •Identify quality trends and opportunities for improvement, and provide feedback, coaching, and corrective action recommendations.
  • •Serve as a subject matter expert (SME) on appeals processing, utilization management, and medical necessity review, including guidance to Clinical Reviewers for Medical Director review.
  • •Ensure appeal reviews and determinations comply with State, Federal, Medicaid, and NCQA requirements, including tracking timeliness and maintaining documentation and audit records.

Pay and Benefits

Salary: USD 81,120
Perks:Health InsuranceDentalVision401kPaid Leave

Key Requirements

  • •3 years of experience in appeals processing, clinical review, or utilization management.
  • •1 year of experience in an advanced role as a Quality Analyst (QA), Team Lead, Trainer, or Subject Matter Expert (SME).
  • •Strong knowledge of utilization management and appeals processes, including Medicaid regulations, NCQA standards, and medical necessity review guidelines.
  • •Ability to review and interpret medical records and clinical documentation, with strong analytical and problem-solving skills.
  • •Active Licensed Practical Nurse (LPN) license required, including Florida state-required licensure or Compact State LPN license.
Experience:3+ years
Skills:Analytical thinkingProblem-solvingWritten communicationVerbal communicationOrganizational skills
Licenses:Active Licensed Practical Nurse (LPN) license

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