BPO Clinical Review Specialist

NTT
Philippines
Workplace: OnsiteFull timeFunction: Product ManagementExperience: 1-3 yearsSkills: ["Communication","Analytic skills","Independent work","Judgment","Attention to detail"]

Review medical records and clinical data to determine medical necessity and support appeal resolution for Medicaid members. Provide subject matter expertise and training to prepare case reviews for Medical Directors, ensuring timely, accurate processing aligned with NCQA and state/federal standards. Communicate with providers, facilities, and internal teams, generate member/provider appeal communications, and use clinical judgement to keep non-routine appeals moving. Maintain appeal files and drive consistency and process improvements.

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FursaFursa
NTT
NTT
1 week ago

BPO Clinical Review Specialist

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Last checked: 4 hours agoStatus: Live

Job Summary

Review medical records and clinical data to determine medical necessity and support appeal resolution for Medicaid members. Provide subject matter expertise and training to prepare case reviews for Medical Directors, ensuring timely, accurate processing aligned with NCQA and state/federal standards. Communicate with providers, facilities, and internal teams, generate member/provider appeal communications, and use clinical judgement to keep non-routine appeals moving. Maintain appeal files and drive consistency and process improvements.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Product Management
Seniority: Mid level

Key Responsibilities

  • •Review medical records and clinical data to determine medical necessity for services per policies, guidelines, and NCQA standards.
  • •Provide guidance and prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing appeal basis.
  • •Ensure timely review, accurate processing, and responses to appeals in line with state, federal, and NCQA standards.
  • •Review claim appeals for reconsideration and recommend approvals/denials or prepare presentations for medical review.
  • •Communicate with providers, facilities, and other departments; generate appeal resolution communications and maintain appeal files; support process improvements to prevent recurrences.

Key Requirements

  • •1-3 years of experience in processing appeals or utilization management.
  • •1 year of experience in advanced roles such as team lead, trainer, SME, or QA.
  • •RN licensure: Registered Nurse with state required licensure and/or Compact State Licensure.
  • •Knowledge of utilization management processes and NCQA standards.
  • •Good communication with strong reading comprehension and writing skills, plus analytic ability to work independently.
Experience:1-3 years
Skills:CommunicationAnalytic skillsIndependent workJudgmentAttention to detail
Licenses:Registered Nurse (RN)

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