Clinical Review Specialist

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

Conduct clinical reviews for Medicaid appeals by analyzing medical records and clinical data to determine medical necessity in line with NCQA, State, and Federal standards. Prepare case reviews for Medical Directors, ensure timely processing and responses, and communicate with providers and facilities. Maintain appeal files, generate member/provider communications and reporting, and support process improvements to increase consistency and appropriateness of appeal resolutions.

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FursaFursa
NTT
NTT
2 weeks ago

Clinical Review Specialist

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

Job Summary

Conduct clinical reviews for Medicaid appeals by analyzing medical records and clinical data to determine medical necessity in line with NCQA, State, and Federal standards. Prepare case reviews for Medical Directors, ensure timely processing and responses, and communicate with providers and facilities. Maintain appeal files, generate member/provider communications and reporting, and support process improvements to increase consistency and appropriateness of appeal resolutions.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Research appeals and review applicable criteria to prepare case reviews for Medical Directors.
  • •Review appeals for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
  • •Ensure timely processing and responses for appeals in accordance with State, Federal, and NCQA standards.
  • •Communicate with providers, facilities, and other departments regarding appeal requests and maintain appeal files.
  • •Work with leadership and interdepartmental teams to improve consistency, efficiency, and appropriateness of appeal responses and prevent recurrences.

Key Requirements

  • •1-3 years of experience processing appeals or in 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, plus analytic and independent work capability.
Experience:1-3 yearsHealthcareUtilization management
Skills:CommunicationIndependent workAnalytic skillsSound judgmentReading comprehensionWriting skills
Licenses:RN
Tech Stack:NCQAMedicaidUtilization managementAppeals processing

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