Clinical Appeals SME & Training Lead

NTT DATA North America; Quezon City; On-site; PHP 558,000 - 1,339,000; Full time

Job summary

NTT DATA North America is seeking a Nurse reviewer to perform training and provide subject matter expertise on clinical reviews needed to resolve and process appeals.

You will review medical records and NCQA criteria, guide case preparations for Medical Directors, and ensure timely processing of all appeal requests.

Requirements include RN licensure, 1–3 years in appeals or utilization management, strong written communication, and availability for US daytime shifts.

Qualifications

• 1–3 years of experience in processing appeals or utilization management.

Responsibilities

• Reviews medical records and clinical data to determine medical necessity for services in accordance with policies and NCQA standards.

Skills

Communication

Analytical skills

Independent work

Education

RN license

Job description

NTT DATA North America is seeking a Nurse reviewer to perform training and provide subject matter expertise on clinical reviews needed to resolve and process appeals.

You will review medical records and NCQA criteria, guide case preparations for Medical Directors, and ensure timely processing of all appeal requests.

Requirements include RN licensure, 1–3 years in appeals or utilization management, strong written communication, and availability for US daytime shifts.