Remote USRN: Utilization Review & Medical Appeals

NTT DATA, Inc.

Manila

On-site

PHP 446,400 - 892,800

Full time

14 days+

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Job summary

NTT DATA Services in Manila seeks a Utilization Review Medical Appeals Nurse (USRN) to join our team. The role focuses on clinical reviews to determine medical necessity, preparing case reviews for Medical Directors, and ensuring timely processing per NCQA and regulatory standards.

Excellent communication is essential, with ability to work remotely. The USRN will coordinate with providers and departments, improve appeals processes, and maintain files for appeals while aligning with Medicaid

Qualifications

1–3 years of experience in processing appeals or utilization management.
US Registered Nurse (USRN).
Knowledge of utilization management process.
Knowledge of NCQA, Medicaid regulations.
Good communication (strong reading comprehension and writing skills).
Ability to work independently, strong analytic skills.
Required shift timings – US daytime.
Can work remotely.

Responsibilities

Performs clinical reviews to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services.
Prepares case reviews for Medical Directors by researching the appeal, reviewing criteria, and analyzing basis for the appeal.
Ensures timely review, processing, and response to appeal per 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.