BPO Medical Records Specialist

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

Review and process Medicaid-related medical necessity and claim appeal cases, researching appeal details and applicable criteria to prepare case reviews for Medical Directors. Ensure timely, accurate appeal responses aligned to State, Federal, and NCQA standards, and generate member/provider resolution communications and reporting. Coordinate with providers and internal teams, maintain appeal files, and support process improvements for consistency, efficiency, and prevention of recurrences. Required shift timings are US daytime.

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FursaFursa
NTT
NTT
1 month ago

BPO Medical Records Specialist

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Source: Company careers pageValidated by: Fursa AI
Last checked: 15 hours agoStatus: Live
Reposted: similar role first listed 1 month ago

Job Summary

Review and process Medicaid-related medical necessity and claim appeal cases, researching appeal details and applicable criteria to prepare case reviews for Medical Directors. Ensure timely, accurate appeal responses aligned to State, Federal, and NCQA standards, and generate member/provider resolution communications and reporting. Coordinate with providers and internal teams, maintain appeal files, and support process improvements for consistency, efficiency, and prevention of recurrences. Required shift timings are US daytime.
Location: Manila
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Research appeal details and applicable criteria to prepare case reviews for Medical Directors.
  • •Ensure timely, accurate processing and responses to appeals per State, Federal, and NCQA standards.
  • •Perform clinical reviews as needed, including reviewing claim appeals for reconsideration and recommending approvals/denials.
  • •Communicate with providers, facilities, and internal departments regarding appeal requests and resolution communication.
  • •Maintain and analyze appeal files by gathering, reviewing, and reporting verbal and written member/provider appeals.

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 with state required Licensure and/or Compact State Licensure.
  • •Knowledge of utilization management processes.
  • •Knowledge of NCQA and Medicaid regulations.
Experience:1-3 years
Skills:CommunicationReading comprehensionWriting skillsAnalytic skillsIndependent work
Certifications: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