Remote Clinical Appeals Specialist (Florida)

NTT DATA, Inc.; Florida; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical, dental, vision insurance with

Employer contribution

S/HSA or FSA

Life and AD&D insurance

Paid time off

401k with company match

Disability coverage

Employee assistance program

Job summary

NTT DATA, Inc. is seeking a Clinical Reviewer Specialist to perform clinical and medical necessity reviews to support appeals processing.

You will evaluate medical records and criteria, prepare recommendations for Medical Director review, and ensure compliance with NCQA, Medicaid, and state regulations. The role is fully remote within Florida, requiring 3 years of relevant experience in appeals processing or clinical review operations.

Qualifications

• Knowledge of utilization management and medical necessity review processes.
• Understanding of NCQA standards, Medicaid regulations, and healthcare appeals requirements.
• Strong analytical and critical-thinking skills with ability to interpret medical records.

Responsibilities

• Conduct comprehensive clinical reviews of medical records to evaluate medical necessity for appealed services.
• Research appeal cases and prepare detailed case reviews for Medical Directors.
• Review claim and service appeals for reconsideration and make recommendations per guidelines.
• Prepare case documentation for Medical Director review and final adjudication.
• Ensure timely review, processing, and resolution of appeals in compliance with regulations.
• Communicate effectively with providers, facilities, Medical Directors, and internal teams.
• Identify trends and opportunities for process improvement in clinical appeals.

Skills

Utilization management

Medical necessity review

NCQA standards

Medicaid regulations

Appeals processing

Analytical reasoning

Communication with providers

Tools

Regulatory knowledge

Job description

NTT DATA, Inc. is seeking a Clinical Reviewer Specialist to perform clinical and medical necessity reviews to support appeals processing.

You will evaluate medical records and criteria, prepare recommendations for Medical Director review, and ensure compliance with NCQA, Medicaid, and state regulations. The role is fully remote within Florida, requiring 3 years of relevant experience in appeals processing or clinical review operations.