BPO Clinical Review Specialist

Req ID:  383426  

NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.

We are currently seeking a BPO Clinical Review Specialist to join our team in Quezon City, Quezon (PH-QUE), Philippines (PH).

Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals to team members.
• Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. 
Roles and Responsibilities:
• Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. 
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. 
• Ensures timely review, accurate processing, and response to appeal in accordance with State, Federal and NCQA standards.
• May also perform clinical reviews. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
• Communicates with providers, facilities and other departments regarding appeal requests. 
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards. 
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests. 
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices. 
• Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review. 
• Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards. 
• Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals. 

• 1-3 years of experience in processing appeals or utilization management. 
• 1 yr experience in advanced roles such as team lead, trainer, SME, or QA
• RN - Registered Nurse - State required Licensure and/or Compact State Licensure
• Knowledge of utilization management process 
• Knowledge of NCQA, Medicaid requlations
• Good communication (Demonstrate strong reading comprehension and writing skills)
• Able to work independently, strong analytic skills
• Required shift timings - US daytime

About NTT DATA

NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D.

Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client’s needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. NTT DATA recruiters will never ask for payment or banking information and will only use @nttdata.com, @nttdatafed.com and @talent.nttdataservices.com email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, 

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