BPO Medical Records Specialist

NTT DATA, Inc.; Philippines; On-site; PHP 279,000 - 446,000; Full time

Job summary

NTT DATA, Inc. is seeking a BPO Medical Records Specialist to join our Manila team. The role involves researching appeals, preparing case reviews for Medical Directors, and ensuring timely processing in line with NCQA and Medicaid standards.

You will communicate with providers and other departments, perform clinical reviews when needed, and help improve the overall appeals process. The position requires RN licensure and 1–3 years of related experience, with US daytime shifts.

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.
• Knowledge of utilization management process.
• Knowledge of NCQA, Medicaid regulations.
• Good communication, reading comprehension and writing skills.
• Able to work independently, strong analytic skills.
• Required shift timings - US daytime.

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.
• 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 and 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.
• Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review.
• Uses sound judgement 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.

Skills

Medical Records

Appeals Processing

Clinical Review

Communication

Analytical Skills

Independence

Education

RN License

Job description

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.

NTT DATA recruiters will never ask for payment or banking information and will only use @nttdata.com, @nttdatafed.com and @talent.nttdataservices.com email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, https://us.nttdata.com/en/contact-us .

NTT DATA endeavors to make https://us.nttdata.com accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at https://us.nttdata.com/en/contact-us . This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. 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 .

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 and 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.

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 regulations.
• Good communication (Demonstrate strong reading comprehension and writing skills).
• Able to work independently, strong analytic skills.
• Required shift timings - US daytime.