BPO Medical Records Specialist

NTT DATA, Inc.; Metro Manila; On-site; PHP 300,000 - 600,000; Full time

Benefits offered by this job

RN benefits

Job summary

NTT DATA, Inc. in Manila, Philippines is seeking a BPO Medical Records Specialist to support Medicaid and NCQA compliant appeals processing.

The role involves researching appeals, preparing case reviews, and communicating with providers and facilities to ensure timely, accurate decisions. The ideal candidate will have 1–3 years in appeals or utilization management, RN licensure, and strong analytical and written communication skills.

Qualifications

• 1–3 years of appeals or utilization management experience.
• RN - Registered Nurse with state licensure.
• Knowledge of utilization management, NCQA, Medicaid regulations.
• Strong reading and writing communication skills; ability to work independently.

Responsibilities

• Research appeals for Medical Directors by reviewing criteria and basis for appeal.
• Prepare case reviews and ensure timely processing per standards.
• Communicate with providers and facilities regarding requests for appeals.
• Generate appeal resolution communications and reports for members and providers.
• Collaborate with leadership to improve the consistency and efficiency of responses to all appeal requests.
• Maintain files on individual appeals with documentation of verbal and written member and provider appeals.

Skills

RN license

Communication

Analytical

Independent worker

Education

RN - State licensure

Job description

Req ID: 379940

NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization,

We are currently seeking a BPO Medical Records Specialist to join our team in Manila, Quezon (PH-QUE), Philippines (PH).

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.
• 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

About NTT DATA

NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D.

Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client’s needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees.

NTT DATA is an equal opportunity employer. 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 our EEO Policy Statement, please click here. If you'd like more information on your EEO rights under the law, please click here. For Pay Transparency information, please click here.