BPO Clinical Review Specialist

NTT
Florida
Workplace: RemoteFull timeUSD 62,150+Function: Product ManagementExperience: 3+ yearsSkills: ["Analytical skills","Critical thinking","Communication","Organizational skills","Problem-solving"]

Perform clinical and medical-necessity reviews for member and provider appeals, analyzing medical records and applicable criteria to prepare recommendations for Medical Director approval. Ensure determinations and communications comply with organizational policies, state/federal regulations, Medicaid requirements, and NCQA standards. Maintain accurate appeal documentation, generate decision letters, and collaborate with internal teams to improve appeal workflows and turnaround-time objectives. Fully remote for residents of Florida only.

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FursaFursa
NTT
NTT
2 weeks ago

BPO Clinical Review Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 8 hours agoStatus: Live
Reposted: similar role first listed 2 weeks ago

Job Summary

Perform clinical and medical-necessity reviews for member and provider appeals, analyzing medical records and applicable criteria to prepare recommendations for Medical Director approval. Ensure determinations and communications comply with organizational policies, state/federal regulations, Medicaid requirements, and NCQA standards. Maintain accurate appeal documentation, generate decision letters, and collaborate with internal teams to improve appeal workflows and turnaround-time objectives. Fully remote for residents of Florida only.
Location: Florida
Workplace: Remote
Employment Type: Full time
Job Function: Product Management
Seniority: Mid level

Key Responsibilities

  • •Conduct comprehensive clinical reviews of medical records to evaluate medical necessity for appealed services.
  • •Research appeal cases and prepare detailed reviews for Medical Director consideration based on criteria and clinical documentation.
  • •Review claim and service appeals for reconsideration and recommend decisions according to established guidelines.
  • •Generate accurate appeal determination letters, communications, and reports for members and providers while maintaining complete records.
  • •Support timely, compliant appeal processing and collaborate on process improvements to enhance quality and turnaround-time objectives.

Pay and Benefits

Salary: USD 62,150
Perks:Health InsuranceDentalVisionPaid Leave401kLife Insurance

Key Requirements

  • •Active Licensed Practical Nurse (LPN) license required (not encumbered).
  • •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.
  • •Strong written and verbal communication skills for documenting and communicating appeal decisions and recommendations.
Experience:3+ yearsHealthcareManaged care
Skills:Analytical skillsCritical thinkingCommunicationOrganizational skillsProblem-solving
Licenses:LPN

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