3 weeks ago

BPO Medical Records Specialist

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Last checked: 22 hours agoStatus: Live

Job Summary

Review and process healthcare claim appeals by researching case information, applying applicable criteria, and preparing case reviews for Medical Directors. Ensure timely, accurate appeal resolutions in line with State, Federal, and NCQA standards, and communicate outcomes to members and providers. May perform clinical reviews and support reconsideration decisions (approve/deny). Maintain appeal files, collaborate with leadership and cross-functional teams to improve processes, and support Medicaid and medical necessity review work.

Location: Manila

Employment Type: Full time

Job Function: Healthcare (Clinical, Medical, Wellness)

Seniority: Mid level

Key Responsibilities

•Research and prepare case reviews for Medical Directors by analyzing the basis for appeals and applicable criteria.
•Ensure timely review, accurate processing, and response to appeals according to State, Federal, and NCQA standards.
•Perform reconsideration reviews and recommend approvals/denials based on determination level or prepare for medical review presentation.
•Communicate with providers, facilities, and internal departments regarding appeal requests and generate resolution communications and reporting.
•Maintain files on individual appeals by gathering, analyzing, and reporting verbal and written member/provider appeals while working to improve appeal processes.

Key Requirements

•1–3 years of experience processing appeals or utilization management.
•1 year of experience in advanced roles such as team lead, trainer, SME, or QA.
•RN—Registered Nurse—state-required licensure and/or Compact State Licensure.
•Knowledge of utilization management processes.
•Knowledge of NCQA and Medicaid regulations; strong reading comprehension and writing skills.

Experience:1-3 years

Skills:CommunicationIndependent workAnalytic skillsJudgmentWriting skills

Licenses:RN license

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

Website LinkedIn

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NTT