Clinical Review Specialist

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

Perform clinical reviews for appeal cases by analyzing medical records and clinical data to determine medical necessity in line with NCQA, Medicaid, and state/federal standards. Prepare case reviews for Medical Directors, ensure timely appeal processing and responses, and communicate with providers and facilities. Generate appeal resolution communications and reports, maintain appeal files, and partner with teams to improve processes and reduce recurring issues. Required shift timings are US daytime.

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FursaFursa
NTT
NTT
1 week ago

Clinical Review Specialist

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Last checked: 23 hours agoStatus: Live

Job Summary

Perform clinical reviews for appeal cases by analyzing medical records and clinical data to determine medical necessity in line with NCQA, Medicaid, and state/federal standards. Prepare case reviews for Medical Directors, ensure timely appeal processing and responses, and communicate with providers and facilities. Generate appeal resolution communications and reports, maintain appeal files, and partner with teams to improve processes and reduce recurring issues. Required shift timings are US daytime.
Location: Philippines
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Prepare case reviews for Medical Directors by researching appeals and analyzing the basis using applicable criteria.
  • •Ensure timely review, processing, and response to appeals according to state, federal, and NCQA standards.
  • •Communicate with providers, facilities, and other departments regarding appeal requests.
  • •Generate appeal resolution communications and reporting for members and providers per company policies and standards.
  • •Maintain and review appeal files, and make recommendations for approval/denial or medical review presentation as appropriate.

Key Requirements

  • •1-3 years of experience processing appeals or utilization management.
  • •RN licensure (State required Licensure and/or Compact State Licensure).
  • •Knowledge of utilization management processes.
  • •Knowledge of NCQA standards and Medicaid regulations.
  • •Strong reading comprehension and writing skills, along with good communication and independent work/analytic skills.
Experience:1-3 yearsHealthcareMedicaidUtilization managementClinical appeals
Skills:CommunicationReading comprehensionWriting skillsIndependent workAnalytic skills
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