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"]

Prepare and coordinate medical claim appeal case reviews for Medical Directors by researching appeals, applying relevant criteria, and ensuring timely, accurate processing in line with State, Federal, and NCQA standards. Review reconsideration appeals, recommend approvals or denials, support clinical reviews when needed, and communicate resolutions to members and providers. Analyze and maintain appeal files, work with leadership to improve consistency and efficiency, and partner with teams to prevent recurrences.

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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: 3 hours agoStatus: Live
Reposted: similar role first listed 1 month ago

Job Summary

Prepare and coordinate medical claim appeal case reviews for Medical Directors by researching appeals, applying relevant criteria, and ensuring timely, accurate processing in line with State, Federal, and NCQA standards. Review reconsideration appeals, recommend approvals or denials, support clinical reviews when needed, and communicate resolutions to members and providers. Analyze and maintain appeal files, work with leadership to improve consistency and efficiency, and partner with teams to prevent recurrences.
Location: Manila
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the basis for appeals.
  • •Ensure timely review and accurate processing and responses to appeals in accordance with State, Federal, and NCQA standards.
  • •Review claim appeals for reconsideration and recommend approvals or denials based on determination level or prepare for medical review presentation.
  • •Communicate with providers, facilities, and other departments regarding appeal requests, and generate resolution communications and reporting for members and providers.
  • •Maintain files on individual appeals and partner with leadership and interdepartmental teams to improve appeal processes and reduce recurrences.

Key Requirements

  • •1-3 years of experience processing appeals or utilization management.
  • •1 year of advanced experience in team lead, trainer, SME, or QA roles.
  • •RN license with state-required licensure and/or Compact State Licensure.
  • •Knowledge of utilization management and Medicaid requirements/regulations, including NCQA standards.
  • •Strong reading comprehension and writing skills, with good communication and analytical skills.
Experience:1-3 yearsUtilization managementMedical appealsMedicaid
Skills:CommunicationReading comprehensionWriting skillsAnalytic skillsIndependent work
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
WebsiteLinkedIn