Clinical Review Specialist

NTT
Philippines
Workplace: OnsiteFull timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 1-3 yearsSkills: ["Communication","Independent work","Analytic skills","Sound judgement","Writing skills"]

Perform clinical reviews to resolve and process appeals by evaluating medical records and clinical data to determine medical necessity. Prepare case reviews for Medical Directors, ensure timely responses aligned with State, Federal, and NCQA standards, and communicate with providers and facilities. Maintain appeal files, analyze reconsideration/claim appeals for approvals or denials, and make recommendations for medical review. Improve appeals consistency and prevent recurrences through process enhancements.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
NTT
NTT
2 weeks ago

Clinical Review Specialist

✓ Verified Job

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

Source: Company careers pageValidated by: Fursa AI
Last checked: 15 hours agoStatus: Live
Reposted: similar role first listed 2 weeks ago

Job Summary

Perform clinical reviews to resolve and process appeals by evaluating medical records and clinical data to determine medical necessity. Prepare case reviews for Medical Directors, ensure timely responses aligned with State, Federal, and NCQA standards, and communicate with providers and facilities. Maintain appeal files, analyze reconsideration/claim appeals for approvals or denials, and make recommendations for medical review. Improve appeals consistency and prevent recurrences through process enhancements.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing appeal basis.
  • •Ensure timely review, processing, and responses to appeals in line with State, Federal, and NCQA standards.
  • •Communicate with providers, facilities, and other departments regarding appeal requests and resolutions.
  • •Maintain files on individual appeals by gathering, analyzing, and reporting member/provider appeals (verbal and written).
  • •Recommend approvals/denials for reconsideration/claim appeals and prepare case recommendations for medical review presentations as necessary.

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 communication with reading comprehension and writing skills.
Experience:1-3 years
Skills:CommunicationIndependent workAnalytic skillsSound judgementWriting skills
Licenses:RN - Registered Nurse

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