Remote RN: Clinical Appeals & Utilization Review

NTT Group; United States; Remoto; USD 68.000 - 84.000; Tempo pieno

Vantaggi offerti da questo lavoro

Health insurance

401k with company match

Paid time off

Descrizione del lavoro

NTT DATA is seeking a BPO Clinical Review Specialist in the United States, with remote work available for Florida residents. The role requires an active RN license (Florida or Compact) and at least 3 years of appeals, utilization management, or clinical review experience.

Salary is $76,000 and benefits include health coverage, 401(k) with company match, and PTO. Work is US daytime hours with strict remote workspace requirements.

Competenze

• Active RN license required with Florida licensure (or Compact)
• Minimum 3 years in appeals processing, utilization management, case management, or clinical review operations
• Knowledge of Medicaid regulations, NCQA standards, and healthcare appeals requirements
• Strong analytical, reading, and documentation skills
• Ability to work independently with multiple priorities and deadlines
• Experience in managed care or healthcare BPO environments
• Willingness to work U.S. daytime hours and adhere to regulatory requirements

Mansioni

• Conduct comprehensive clinical reviews of medical records to evaluate medical necessity.
• Research appeal cases and prepare detailed reviews for Medical Directors.
• Review claims and service appeals for reconsideration and provide recommendations.
• Prepare recommendations and documentation for Medical Director review.
• Ensure timely review and resolution in compliance with regulations and NCQA standards.
• Maintain complete, accurate appeal records and communications with providers.

Conoscenze

Appeals processing

Utilization management

Case management

Clinical review

Medical necessity

NCQA / Medicaid knowledge

Analytical skills

Excellent communication

Independent work

Regulatory compliance

Formazione

RN license

Descrizione del lavoro

NTT DATA is seeking a BPO Clinical Review Specialist in the United States, with remote work available for Florida residents. The role requires an active RN license (Florida or Compact) and at least 3 years of appeals, utilization management, or clinical review experience.

Salary is $76,000 and benefits include health coverage, 401(k) with company match, and PTO. Work is US daytime hours with strict remote workspace requirements.