BPO Clinical Review Specialist

NTT
United States
Workplace: RemoteFull timeUSD 76,000+Function: Product ManagementExperience: 3+ yearsSkills: ["Analytical thinking","Critical thinking","Communication","Organizational skills","Independent work"]

Perform clinical and medical necessity reviews for member and provider appeals, analyzing medical records and documentation to determine appropriate outcomes. Research cases, prepare detailed recommendations for Medical Director review, and generate appeal determination communications and reports. Ensure decisions and records meet company policies, Medicaid and NCQA requirements, and applicable state and federal regulations. Maintain accurate documentation, communicate with stakeholders, and support continuous improvement of clinical appeals processes.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
NTT
NTT
1 week 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: 18 hours agoStatus: Live

Job Summary

Perform clinical and medical necessity reviews for member and provider appeals, analyzing medical records and documentation to determine appropriate outcomes. Research cases, prepare detailed recommendations for Medical Director review, and generate appeal determination communications and reports. Ensure decisions and records meet company policies, Medicaid and NCQA requirements, and applicable state and federal regulations. Maintain accurate documentation, communicate with stakeholders, and support continuous improvement of clinical appeals processes.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Product Management
Seniority: Mid level

Key Responsibilities

  • •Conduct clinical reviews of medical records and supporting documentation to evaluate medical necessity for appealed services.
  • •Research appeal cases and prepare detailed case reviews for Medical Directors by analyzing applicable criteria and clinical information.
  • •Review claim and service appeals for reconsideration and recommend approvals or denials based on established guidelines.
  • •Prepare appeal determination letters, communications, and reports, and maintain complete, accurate appeal records.
  • •Communicate effectively with providers, healthcare facilities, Medical Directors, and internal teams while ensuring quality and compliance with regulations and NCQA standards.

Pay and Benefits

Salary: USD 76,000
Perks:Health InsuranceDentalVision401kPaid 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 license).
  • •Ability to interpret medical records and clinical documentation and prepare concise case summaries and recommendations with strong communication skills.
Experience:3+ yearsHealthcareHealth planManaged careMedicaidUtilization managementAppeals processing
Skills:Analytical thinkingCritical thinkingCommunicationOrganizational skillsIndependent work
Licenses: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
WebsiteLinkedIn