Remote RN: Clinical Appeals Specialist (Florida)

NTT America, Inc.; Tampa (FL); A distancia; USD 68.000 - 84.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance and benefits package

401k with company match

Paid time off

Dental & Vision insurance

Disability coverage

Descripción de la vacante

NTT America, Inc. is seeking a Clinical Reviewer Specialist to perform clinical and medical necessity reviews to support timely processing of member and provider appeals. You will evaluate medical records, apply criteria, and prepare recommendations for Medical Director review to ensure compliant, high-quality determinations.

This role is fully remote for residents of Florida. You must live in the state with a valid address.

Formación

• 3 years of experience in appeals processing, utilization management, case management, or clinical review operations.
• Knowledge of utilization management and medical necessity review processes.
• Understanding of NCQA standards, Medicaid regulations, and healthcare appeals requirements.
• Strong analytical and communication skills with the ability to interpret medical records and documentation.

Responsabilidades

• Conduct comprehensive clinical reviews to evaluate medical necessity for appealed services.
• Prepare detailed case reviews for Medical Directors by analyzing clinical information and criteria.
• Review claims and services appeals for reconsideration and provide recommendations for final adjudication.

Conocimientos

Appeals processing

Utilization management

NCQA standards

Medical records review

Communication skills

Independent work

Attention to detail

Medicaid experience

Managed care experience

Regulatory knowledge

Time management

Educación

RN license (Florida/Compact)

Descripción del empleo

NTT America, Inc. is seeking a Clinical Reviewer Specialist to perform clinical and medical necessity reviews to support timely processing of member and provider appeals. You will evaluate medical records, apply criteria, and prepare recommendations for Medical Director review to ensure compliant, high-quality determinations.

This role is fully remote for residents of Florida. You must live in the state with a valid address.