BPO Clinical Review Senior Specialist

7 days ago

Metro Manila Philippines NTT DATA North America Full time

NTT DATA seeks a BPO Clinical Review Senior Specialist to join our team in Manila, Philippines. Roles and Responsibilities Provides guidance on preparing case reviews for Medical Directors by researching appeals, reviewing criteria, and analyzing the basis for the appeal. Ensures timely review, processing, and response to appeals in accordance with state, federal, and NCQA standards. May perform clinical reviews. Communicates with providers, facilities, and other departments regarding appeal requests. Generates appropriate appeals resolution communication and reporting for members and providers per company policies. Works with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeal requests. Partners with interdepartmental teams to improve processes and procedures to prevent recurrences based on industry best practices. Uses sound judgement in non‑routine appeals to keep the process moving forward per contractual timeliness standards. Maintains files on individual appeals by gathering, analyzing, and reporting member and provider appeals. Reviews claim appeals for reconsideration and recommends approvals/denials or prepares for medical review presentation. Prepares case recommendations for medical review as necessary. Qualifications 1‑3 years of experience in processing appeals or utilization management. Registered Nurse (RN) with required state licensure or compact state licensure. Knowledge of utilization management processes. Knowledge of NCQA and Medicaid regulations. Strong written and reading comprehension skills. Ability to work independently with strong analytical skills. Required shift timings: U.S. daytime. Seniority Level: Mid‑Senior. Employment Type: Full‑Time. Job Function: Health Care Provider. NTT DATA is a global technology and business services provider. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. For more information on EEO rights, click here. Pay transparency information is available upon request. #J-18808-Ljbffr

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