Remote RN: Clinical Appeals Reviewer (Medicaid)

NTT DATA, Inc.; Tampa (FL); Hybrid; USD 68,000 - 84,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k with company match

Paid time off

Life and AD&D

Job summary

NTT DATA is seeking a BPO Clinical Review Specialist to join our Tampa, FL team. You will perform clinical and medical necessity reviews to support timely processing of member and provider appeals, evaluating records and applying criteria to determine necessity.

The role is fully remote within Florida, requires active RN license, and offers benefits; salary is $76,000 with opportunities for professional growth and compliance with NCQA and Medicaid standards.

Qualifications

• Active RN license
• Florida licensure or compact required
• 3 years of appeals processing or related experience
• Knowledge of Medicaid and NCQA standards
• Strong analytical and communication skills

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 by analyzing clinical information and applicable criteria.
• Review claim and service appeals for reconsideration and make recommendations based on established guidelines.
• Prepare case recommendations and supporting documentation for Medical Director review as required.
• Apply sound clinical judgment when evaluating routine and complex appeal cases.
• Maintain complete appeal records and ensure compliance with regulations and standards.

Skills

Appeals processing

Utilization management

Medical necessity

NCQA standards

Medicaid regulations

Communication skills

Independent work

Documentation

Regulatory compliance

Clinical review

Education

Registered Nurse license

Florida RN license or Compact

Job description

NTT DATA is seeking a BPO Clinical Review Specialist to join our Tampa, FL team. You will perform clinical and medical necessity reviews to support timely processing of member and provider appeals, evaluating records and applying criteria to determine necessity.

The role is fully remote within Florida, requires active RN license, and offers benefits; salary is $76,000 with opportunities for professional growth and compliance with NCQA and Medicaid standards.