NTT

2 weeks ago

BPO Medical Records Specialist

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Last checked: 15 hours agoStatus: Live

Job Summary

Review and process medical claim appeals for Medical Directors and members/providers, researching the appeal and applicable criteria to support timely, accurate decisions. Ensure compliance with State, Federal and NCQA standards, generate resolution communications and reporting, and maintain appeal files. May perform clinical reviews and recommend approval/denial based on determination level, while partnering with teams to improve consistency, efficiency, and appropriateness of appeal outcomes for Medicaid and medical necessity cases.

Location: Manila

Workplace: Onsite

Employment Type: Full time

Job Function: Healthcare (Clinical, Medical, Wellness)

Seniority: Mid level

Key Responsibilities

•Research the appeal, review applicable criteria, and analyze the basis for the appeal to support Medical Director case reviews.
•Ensure timely review, accurate processing, and response to appeals in accordance with State, Federal and NCQA standards.
•Review claims appeals for reconsideration 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 reporting.
•Maintain files on individual appeals by gathering, analyzing, and reporting member and provider appeals; use judgement to keep appeals moving forward per contractual timeliness standards.

Key Requirements

•1-3 years of experience in processing appeals or utilization management.
•1 year 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 communication, reading comprehension, writing, and analytic skills.

Experience:1-3 years

Skills:CommunicationAnalytic skillsJudgementIndependent workReading comprehensionWriting 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