NTT

3 weeks ago

BPO Medical Records Specialist

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Last checked: 23 hours agoStatus: Live

Job Summary

Review and process medical claim appeals to support Medical Directors, researching appeal details and applying applicable criteria. Ensure timely, accurate determinations and communications in line with State, Federal, and NCQA standards, including Medicaid and medical necessity review. Handle reconsideration and potential clinical review work, communicate with providers/facilities and internal teams, and help improve appeal processes for consistency, efficiency, and prevention of recurrences. Maintain well-organized appeal files and reporting.

Location: Manila

Workplace: Onsite

Employment Type: Full time

Job Function: Healthcare (Clinical, Medical, Wellness)

Seniority: Entry level

Key Responsibilities

•Provide guidance to prepare case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing the basis for appeal.
•Ensure timely review, accurate processing, and responses to appeals in accordance with State, Federal, and NCQA standards.
•Perform or support reconsideration review and recommend approvals/denials based on determination level, or prepare for medical review presentation.
•Communicate with providers, facilities, and other departments regarding appeal requests and resolution communications/reporting to members and providers.
•Maintain files on individual appeals by gathering, analyzing, and reporting verbal and written member/provider appeals, and support process improvements to prevent recurrences.

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, with strong reading comprehension and writing for good communication.

Experience:1-3 yearsHealthcareUtilization managementMedicaid

Skills:CommunicationAnalytic skillsIndependent workGood judgementWriting skills

Licenses: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

Website LinkedIn

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NTT