BPO Clinical Review Specialist

NTT
Florida
Workplace: RemoteFull timeUSD 76,000+Function: Product ManagementExperience: 3+ yearsSkills: ["Analytical thinking","Critical thinking","Communication","Organizational skills","Problem-solving"]

Perform clinical and medical necessity reviews for member and provider appeals, evaluating medical records and applicable criteria to support timely, compliant appeal determinations. Prepare detailed case reviews and written communications for Medical Director consideration, ensuring accuracy and adherence to organizational policies, State/Federal regulations, Medicaid requirements, and NCQA standards. Collaborate with internal and external stakeholders and help identify process improvements to increase quality and turnaround time.

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FursaFursa
NTT
NTT
2 weeks ago

BPO Clinical Review Specialist

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 17 hours agoStatus: Live
Reposted: similar role first listed 2 weeks ago

Job Summary

Perform clinical and medical necessity reviews for member and provider appeals, evaluating medical records and applicable criteria to support timely, compliant appeal determinations. Prepare detailed case reviews and written communications for Medical Director consideration, ensuring accuracy and adherence to organizational policies, State/Federal regulations, Medicaid requirements, and NCQA standards. Collaborate with internal and external stakeholders and help identify process improvements to increase quality and turnaround time.
Location: Florida
Workplace: Remote
Employment Type: Full time
Job Function: Product Management

Key Responsibilities

  • •Conduct comprehensive clinical reviews of medical records to evaluate medical necessity for appealed services.
  • •Research appeal cases and prepare detailed recommendations and case reviews for Medical Directors based on applicable criteria.
  • •Review claim and service appeals for reconsideration and provide recommendations within established guidelines.
  • •Ensure timely, accurate appeal processing in compliance with policies, contractual requirements, State/Federal regulations, Medicaid guidelines, and NCQA standards.
  • •Generate appeal determination letters and maintain complete, accurate appeal documentation and communications for members and providers.

Pay and Benefits

Salary: USD 76,000
Perks:Health InsuranceDentalVision401kLife InsurancePaid Leave

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 Registered Nurse (RN) license required (Florida state-required and/or Compact State RN).
  • •Strong analytical/critical-thinking and written/verbal communication skills to interpret clinical documentation and prepare concise case summaries.
Experience:3+ yearsHealthcareManaged care
Skills:Analytical thinkingCritical thinkingCommunicationOrganizational skillsProblem-solving
Licenses:Registered Nurse (RN) - Florida

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