Clinical Review Specialist

NTT DATA, Inc.; Philippines; On-site; PHP 360,000 - 480,000; Full time

Job summary

NTT DATA, Inc. seeks a Registered Nurse to perform clinical reviews of medical appeals and determine medical necessity in line with NCQA and Medicaid requirements.

The role requires 1–3 years in appeals or utilization management and strong communication and analytics. You will prepare case reviews for Medical Directors, ensure timely processing, and coordinate with providers and internal teams to improve appeals workflows.

Qualifications

• 1-3 years of experience in processing appeals or utilization management.
• Registered Nurse with state licensure (or compact license).
• Knowledge of utilization management processes.
• Knowledge of NCQA and Medicaid regulations.
• Strong reading and writing skills; good communication.
• Able to work independently with strong analytical skills.
• Shift timings align with US daytime schedule.

Responsibilities

• 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 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.

Skills

Utilization management

NCQA knowledge

Medicaid regulations

Communication skills

Analytical skills

Independent work

Education

RN licensure

Job description

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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, 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 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.

Required Experience and Qualifications:

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