BPO Clinical Review Specialist

1 day ago

Manila, Philippines NTT DATA, Inc. Full time

Overview Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Responsibilities Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analysing the basis for the appeal. Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards. Communicates with providers, facilities and other departments regarding appeal requests. Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards. Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests. Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices. Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review. Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards. Maintain files on individual appeals by gathering, analysing and reporting verbal and written member and provider appeals. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation. Prepare case recommendations for medical review as necessary. Qualifications 1-3 years of experience in processing appeals or utilization management. RN - Registered Nurse - State required Licensure and/or Compact State Licensure Knowledge of utilization management process Knowledge of NCQA, Medicaid regulations Good communication (Demonstrate strong reading comprehension and writing skills) Able to work independently, strong analytic skills Required shift timings - US daytime Job Segment: Quality Assurance, Technology #J-18808-Ljbffr

  • BPO Clinical Review Senior Specialist

    7 days ago

    Manila, Philippines NTT DATA, Inc. Full time

    NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now. We are currently seeking a BPO Clinical Review Senior Specialist to join our team in Manila, National Capital Region (PH-00), Philippines (PH). Performs training...

  • BPO Clinical Review Specialist

    2 days ago

    Manila, National Capital Region, Philippines The Nippon Telegraph and Telephone Corporation (NTT) Full time ₱600,000 - ₱800,000 per year

    Performs quality audits on clinical reviews needed to resolve and process appeals. Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Roles and Responsibilities:Provides guidance on preparing case reviews for Medical...

  • BPO Clinical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱300,000 - ₱600,000 per year

    Performs quality audits on clinical reviews needed to resolve and process appeals. Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards....

  • BPO Clinical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱300,000 - ₱600,000 per year

    Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria,...

  • BPO Clinical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA North America Full time ₱40,000 - ₱80,000 per year

    Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.Roles and Responsibilities:Prepares case reviews for Medical Directors by researching the appeal,...

  • BPO Clinical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱40,000 - ₱80,000 per year

    Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Roles and Responsibilities: Prepares case reviews for Medical Directors by researching the appeal,...

  • BPO Clinical Review Specialist

    1 week ago

    Manila, National Capital Region, Philippines NTT DATA North America Full time ₱80,000 - ₱120,000 per year

    "Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.Roles and Responsibilities:Prepares case reviews for Medical Directors by researching the appeal,...

  • BPO Clinical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱300,000 - ₱600,000 per year

    Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards. Communicates with providers, facilities and other departments regarding appeal requests. Generates...

  • BPO Clinical Review Senior Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱300,000 - ₱600,000 per year

    Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals. Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. Ensures timely review, processing, and response to appeal in accordance with...

  • BPO Clinical Review Senior Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA North America Full time ₱40,000 - ₱80,000 per year

    Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals. Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.Roles and Responsibilities:Provides guidance on...