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","Sound judgement"]

Perform clinical reviews to resolve and process appeals by evaluating medical records and clinical data to determine medical necessity under policies, guidelines, and NCQA standards. Prepare case reviews for medical directors, ensure timely appeal processing and responses, and communicate with providers and facilities. Generate appeal resolution communications and reports, maintain appeal files, and recommend approvals/denials or prepare cases for medical review, improving consistency and efficiency of appeal outcomes.

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FursaFursa
NTT
NTT
1 week ago

Clinical Review Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 4 hours agoStatus: Live

Job Summary

Perform clinical reviews to resolve and process appeals by evaluating medical records and clinical data to determine medical necessity under policies, guidelines, and NCQA standards. Prepare case reviews for medical directors, ensure timely appeal processing and responses, and communicate with providers and facilities. Generate appeal resolution communications and reports, maintain appeal files, and recommend approvals/denials or prepare cases for medical review, improving consistency and efficiency of appeal outcomes.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •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.
  • •Generate appeals resolution communication and reporting for members and providers per company policies and applicable standards.
  • •Maintain files on appeals by gathering, analyzing, and reporting verbal and written member/provider appeal information; recommend approvals/denials or prepare for medical review presentations.

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 process.
  • •Knowledge of NCQA and Medicaid regulations.
  • •Strong communication with reading comprehension and writing skills, plus analytical judgement to handle non-routine appeals.
Experience:1-3 yearsUtilization management
Skills:CommunicationReading comprehensionWriting skillsIndependent workAnalytic skillsSound judgement
Licenses:Registered Nurse (RN) 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