Remote RN: Medical Appeals Reviewer (Florida)

NTT DATA, Inc.; Tempe (AZ); Remote; USD 68,000 - 84,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Employer 401k match

Paid time off

Life and AD&D insurance

Short- and long-term disability

Employee assistance program

Job summary

NTT DATA, Inc. seeks a Clinical Reviewer Specialist to perform clinical and medical necessity reviews for member and provider appeals, evaluating records against NCQA standards and Medicaid requirements.

Role offers remote work within Florida, requires RN licensure, 3 years’ experience in appeals or related fields, and duties include preparing case summaries and recommendations for Medical Directors, with collaboration across stakeholders.

Qualifications

• 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 critical-thinking skills with the ability to interpret medical records and clinical documentation.
• Excellent written and verbal communication skills, including strong reading comprehension and documentation abilities.
• Ability to work independently while managing multiple priorities and deadlines.
• Strong organizational and problem-solving skills.
• Proficiency in researching clinical criteria and preparing concise case summaries and recommendations.
• Experience supporting Medicaid appeals and utilization management programs.
• Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment.
• Familiarity with regulatory and accreditation requirements governing appeals and grievance processes.
• Required to work U.S. daytime business hours.
• Flexibility may be required based on operational and business needs.
• Strong clinical assessment and medical necessity review skills.
• Attention to detail and commitment to quality and compliance.
• Ability to make sound decisions in complex and non-routine appeal situations.
• Effective communication and collaboration with internal and external stakeholders.
• Commitment to timely, accurate, and member-focused appeal resolution.

Responsibilities

• Conduct comprehensive clinical reviews of medical records and supporting documentation to evaluate medical necessity for appealed services.
• Research appeal cases and prepare detailed case reviews for Medical Directors by analyzing clinical information, applicable criteria, and the basis for the appeal.
• Review claim and service appeals for reconsideration and make recommendations based on established guidelines and determination authority for senior reviewer to make final adjudication of claim approval or denial
• Prepare case recommendations and supporting documentation for Medical Director review as required.
• Apply sound clinical judgment when evaluating routine and complex appeal cases.
• Ensure timely review, processing, and resolution of appeals in accordance with company policies, contractual requirements, State and Federal regulations, Medicaid guidelines, and NCQA standards.
• Generate accurate appeal determination letters, communications, and reports for members and providers.
• Maintain complete and accurate appeal records and documentation throughout the review process.
• Ensure appeal decisions and supporting documentation meet quality and compliance requirements.
• Communicate effectively with providers, healthcare facilities, Medical Directors, and internal departments regarding appeal requests and supporting clinical information.
• Collaborate with leadership and operational teams to improve the consistency, accuracy, and appropriateness of appeal review outcomes.
• Partner with cross-functional teams to identify opportunities for process improvement and enhanced operational performance.
• Participate in discussions regarding complex cases and escalation reviews.
• Support initiatives to improve clinical appeals processes, workflows, and service quality.
• Identify trends and recurring issues within appeals and recommend process improvements based on best practices.
• Maintain current knowledge of medical necessity guidelines, utilization management practices, Medicaid requirements, and NCQA standards.
• Contribute to achieving departmental quality, productivity, and turnaround-time objectives.

Skills

Appeals processing

Utilization management

Case management

Clinical review

NCQA standards

Medicaid regulations

Medical necessity review

Communication skills

Independent work

Organizational skills

Education

RN licensure

Florida RN licensure/Compact

Job description

NTT DATA, Inc. seeks a Clinical Reviewer Specialist to perform clinical and medical necessity reviews for member and provider appeals, evaluating records against NCQA standards and Medicaid requirements.

Role offers remote work within Florida, requires RN licensure, 3 years’ experience in appeals or related fields, and duties include preparing case summaries and recommendations for Medical Directors, with collaboration across stakeholders.