BPO Clinical Review Specialist at NTT DATA

Manila, Metro Manila, Philippines -

Full Time

Start Date

Immediate

Expiry Date

26 Jan, 26

Salary

0.0

Posted On

28 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Review, Medical Records, Clinical Data, Medical Necessity, Appeals Processing, Communication, Research, Analysis, Judgment, Utilization Management, Medicaid, Case Recommendations, Timeliness Standards, Interdepartmental Collaboration, Policies and Procedures, NCQA Standards

Industry

IT Services and IT Consulting

Description

Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analysing the basis for the appeal. Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards. 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, analysing and reporting verbal and written member and provider appeals. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation. Prepare case recommendations for medical review as necessary. 1-3 years of experience in processing appeals or utilization management. RN - Registered Nurse - State required Licensure and/or Compact State Licensure Good communication (Demonstrate strong reading comprehension and writing skills)

Responsibilities

The BPO Clinical Review Specialist performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data. They ensure timely processing and communication regarding appeal requests in accordance with relevant standards.