Medical Records Specialist

1 week ago

Manila, National Capital Region, Philippines NTT DATA, Inc. Full time
Responsibilities
  • 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 members, providers, facilities, and other departments regarding appeals requests
  • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
  • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals 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 Medicare and medical necessity review.
  • Uses sound judgment, 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, analyzing 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.
Requirements
  • 2 - 4 years of experience in processing appeals or utilization management
  • RN - Registered Nurse – State required Licensure and/or Compact State Licensure
  • Knowledge of utilization management processes
  • Knowledge of NCQA, Medicare and Medicaid regulations
  • Good communication (Demonstrate strong reading comprehension and writing skills)
  • Able to work independently, strong analytic skills

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