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. 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 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 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 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...

  • 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 Manager

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA North America Full time ₱1,200,000 - ₱2,400,000 per year

    Supervises team that 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...

  • BPO Manager

    2 weeks ago

    Manila, National Capital Region, Philippines NTT DATA Full time ₱400,000 - ₱800,000 per year

    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...

  • Medical Review Specialist

    2 weeks ago

    Manila, National Capital Region, Philippines TakeCare Insurance Company, Inc. Full time ₱300,000 - ₱600,000 per year

    Job Specifications:Graduate of Bachelor's Degree – RN License is required.Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources.Effective team player. Excellent interpersonal relationship...

  • USRN TeamLead

    2 weeks ago

    Manila, National Capital Region, Philippines Global Group Innovative Services, Inc. Full time ₱70,000 - ₱93,500 per year

    HIRING: USRN Team Lead (Work from Home)Location: Bridgetowne, Quezon CityWork Setup: Work from Home (WAH)Schedule: Night Shift | Monday to FridaySalary Range: ₱70,000 – ₱78,500 + ₱15,000 License PremiumTake your leadership career to the next level with a leading healthcare BPO organization We're looking for a strong and experienced USRN Team Lead to...