BPO Medical Records Specialist

NTT
Manila
Full timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 1-3 yearsSkills: ["Communication","Reading comprehension","Writing","Independent work","Analytical skills","Sound judgment"]

Review and process Medicaid medical-necessity and claim appeal cases by researching appeals, applying applicable criteria, and supporting timely, accurate decisions. Prepare case reviews and appeal resolution communications for members and providers in line with State, Federal, and NCQA standards. Communicate with providers and internal teams, maintain appeal records, and help improve consistency and efficiency of clinical appeals processes. May also perform clinical reviews based on determination level.

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FursaFursa
NTT
NTT
4 weeks ago

BPO Medical Records Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 21 hours agoStatus: Live
Reposted: similar role first listed 4 weeks ago

Job Summary

Review and process Medicaid medical-necessity and claim appeal cases by researching appeals, applying applicable criteria, and supporting timely, accurate decisions. Prepare case reviews and appeal resolution communications for members and providers in line with State, Federal, and NCQA standards. Communicate with providers and internal teams, maintain appeal records, and help improve consistency and efficiency of clinical appeals processes. May also perform clinical reviews based on determination level.
Location: Manila
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Research appeals and prepare case reviews for Medical Directors by reviewing applicable criteria and analyzing the basis for the appeal.
  • •Ensure timely review, accurate processing, and response to appeals in accordance with State, Federal, and NCQA standards.
  • •Review claim appeals for reconsideration and recommend approvals/denials or prepare for medical review presentations.
  • •Communicate with providers, facilities, and other departments regarding appeal requests and resolution updates.
  • •Maintain files on individual appeals and work with leadership to improve consistency, efficiency, and appropriateness of responses.

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 and NCQA and Medicaid regulations.
  • •Demonstrate strong reading comprehension and writing skills with good communication.
  • •Ability to work independently with strong analytical skills and sound judgment for non-routine appeals.
Experience:1-3 yearsHealthcareUtilization managementMedicaid
Skills:CommunicationReading comprehensionWritingIndependent workAnalytical skillsSound judgment
Licenses:RNRegistered Nurse
Tech Stack:NCQAMedicaid

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