NTT

4 weeks ago

Clinical Reviewer Specialist

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Last checked: 4 hours agoStatus: Live

Job Summary

Review medical records and clinical data to resolve and process appeals by determining medical necessity in line with NCQA, State, and Federal standards. Prepare case reviews for Medical Directors, analyze appeal criteria, and ensure timely processing and responses. Communicate with providers and facilities, generate member/provider resolution reporting, and maintain appeal documentation. Work with leadership and cross-functional teams to improve appeal consistency and efficiency, including Medicaid-focused utilization management reviews.

Location: Manila

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 for appeals per policies, guidelines, and NCQA standards.
•Prepare case reviews for Medical Directors by researching appeals, applying criteria, and analyzing appeal basis.
•Ensure timely appeal review, processing, and response according to State, Federal, and NCQA standards.
•Communicate with providers, facilities, and other departments about appeal requests and generate resolution communication/reporting.
•Maintain files for appeals by gathering, analyzing, and reporting verbal and written member/provider appeals, and recommend approvals/denials or prepare for medical review presentation.

Key Requirements

•1-3 years of experience 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, writing, and communication skills, with analytic ability to work independently.

Experience:1-3 years

Skills:CommunicationReading comprehensionWritingAnalytic skillsIndependent work

Licenses:State required licensureCompact State Licensure

Certifications:Registered Nurse (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

Website LinkedIn

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NTT