BPO Clinical Review Specialist

NTT
Florida
Workplace: RemoteFull timeUSD 62,150+Function: Product ManagementExperience: 3+ yearsSkills: ["Analytical thinking","Critical thinking","Written communication","Verbal communication","Organizational skills"]

Perform clinical and medical-necessity reviews for member and provider appeals, evaluating medical records and applicable criteria to determine approvals or denials for Medical Director review. Ensure compliance with organizational policies, State/Federal regulations, Medicaid requirements, and NCQA standards, while producing clear appeal determinations and maintaining accurate documentation. This fully remote (Florida-only) role requires strong clinical judgment, analytical skills, and reliable performance during U.S. daytime business hours.

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FursaFursa
NTT
NTT
1 week ago

BPO Clinical Review Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 20 hours agoStatus: Live

Job Summary

Perform clinical and medical-necessity reviews for member and provider appeals, evaluating medical records and applicable criteria to determine approvals or denials for Medical Director review. Ensure compliance with organizational policies, State/Federal regulations, Medicaid requirements, and NCQA standards, while producing clear appeal determinations and maintaining accurate documentation. This fully remote (Florida-only) role requires strong clinical judgment, analytical skills, and reliable performance during U.S. daytime business hours.
Location: Florida
Workplace: Remote
Employment Type: Full time
Job Function: Product Management
Seniority: Mid level

Key Responsibilities

  • •Conduct clinical reviews of medical records to evaluate medical necessity for appealed services.
  • •Research appeal cases and prepare case reviews for Medical Director consideration using clinical information and applicable criteria.
  • •Review claim/service appeals for reconsideration and recommend approvals or denials based on guidelines.
  • •Generate accurate appeal determination letters, communications, and reports for members and providers.
  • •Maintain complete appeal records and ensure decisions and documentation meet quality and compliance requirements.

Pay and Benefits

Salary: USD 62,150
Perks:Health InsuranceDentalVision401kLife InsuranceLong-term DisabilityPaid LeaveHsa

Key Requirements

  • •3 years of experience in appeals processing, utilization management, case management, or clinical review operations.
  • •Knowledge of utilization management and medical necessity review processes.
  • •Understanding of NCQA standards, Medicaid regulations, and healthcare appeals requirements.
  • •Active Licensed Practical Nurse (LPN) license required (Florida and/or Compact State).
  • •Strong analytical/communication skills to interpret clinical documentation and prepare concise case summaries and recommendations.
Experience:3+ yearsHealthcareHealth plansManaged careUtilization managementClinical reviewMedicaid appealsHealthcare BPO
Skills:Analytical thinkingCritical thinkingWritten communicationVerbal communicationOrganizational skills
Licenses:LPN

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