BPO Clinical Review Senior Specialist

6 days 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 State, Federal and NCQA standards. May also perform clinical reviews. 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-rooutine 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 recommemdations for medical review as necessary. 1-3 years of experience in processing appeals or utilization management. RN - Registered Nurse - State required Licensure and/or Compact State Licensure Good communication (Demonstrate strong reading comprehension and writing skills)

  • BPO Clinical Review Senior Specialist

    6 days 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...

  • BPO Clinical Review Specialist

    6 days 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

    6 days 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

    4 days 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

    6 days 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

    6 days 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

    6 days 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...

  • Clinical Authorization Specialist

    4 days ago

    Manila, National Capital Region, Philippines LKN Strategies Inc Full time ₱384,000 - ₱456,000 per year

    Clinical Authorization SpecialistCompany ProfileLKN Strategies is an established healthcare BPO provider with locations in the US, Philippines, and India. LKN is an employee-centric company that offers its employees competitive salaries, robust benefits packages, incentive bonuses, best-in-industry training, professional development, work-from-home...

  • Compliance Specialist

    2 days ago

    Manila, National Capital Region, Philippines Eden Senior Care Full time ₱1,500,000 - ₱3,000,000 per year

    Job Title:Compliance SpecialistTime Zone:9 AM to 5 PM Central Standard Time (CST)About Eden Senior Care:Eden Senior Care is a dynamic and rapidly growing senior living operator. We are committed to providing exceptional care and creating vibrant communities for our residents. We are seeking a Compliance Specialist to join our team and ensure that our...

  • Senior Social Worker and Clinical Coordinator

    2 weeks ago

    Manila, National Capital Region, Philippines Women's and Children's Health Network Full time ₱108,000 - ₱116,000 per year

    Women's and Children's Health Network, Sub Acute and Allied Health, Child Development Unit, Kaurna Land, North Adelaide 5006SalaryClassification - AHP3 - Allied Health Professional L3- $108,347.00 to $116, Superannuation and Salary Sacrifice BenefitsPart Time (0.4 FTE) – Term Contract (Temporary until 30 June 2026)About The OpportunityWe currently have an...