BPO Clinical Review Specialist

NTT DATA, Inc.; Quezon City; On-site; PHP 400,000 - 700,000; Full time

Job summary

NTT DATA, Inc. is seeking an experienced clinician to join our healthcare appeals team in the Philippines.

The role focuses on training and providing SME-level expertise for clinical reviews needed to resolve and process appeals, ensuring medical necessity determinations align with NCQA standards. The ideal candidate has RN licensure and 1–3 years in processing appeals or utilization management, with strong communication and independent work capabilities.

Qualifications

• 1-3 years of experience in processing appeals or utilization management.
• 1 year experience in advanced roles such as team lead, trainer, SME, or QA.
• RN licensure (US state or compact) to practice.
• Knowledge of utilization management process.
• Knowledge of NCQA and Medicaid regulations.
• Strong reading and writing communication skills.
• Ability to work independently with strong analytical skills.
• Required shift timings - US daytime hours.

Responsibilities

• Provides training and SME guidance on clinical reviews for appeals.
• Prepares case reviews for Medical Directors by researching appeals and applicable criteria.
• Ensures timely, accurate processing and response to appeals per NCQA and state/federal standards.
• Reviews and may perform clinical reviews to support reconsiderations or medical review presentations.
• Communicates with providers, facilities and departments regarding appeal requests.
• Generates appeal resolution communications and reporting per company policies and NCQA standards.
• Collaborates with leadership to improve consistency and efficiency of responses.
• Partners with interdepartmental teams to improve clinical appeal processes.
• Maintains files on appeals with data gathering, analysis, and reporting.

Skills

Clinical Reviews

Utilization Management

Data Analysis

Verbal & Written Communication

Independent / Self-driven

Education

RN License (US state or compact)

Job description

Job Overview

Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals to team members.

• 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 Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensures timely review, accurate processing, and response to appeal in accordance with State, Federal and NCQA standards.
• May also perform clinical reviews. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
• 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, analyzing and reporting verbal and written member and provider appeals.

Required Qualifications

• 1-3 years of experience in processing appeals or utilization management.
• 1 yr experience in advanced roles such as team lead, trainer, SME, or QA
• RN - Registered Nurse - State required Licensure and/or Compact State Licensure
• Knowledge of utilization management process
• Knowledge of NCQA, Medicaid requlations
• 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