BPO Clinical Review Senior Specialist

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 Senior Specialist to join our team in Manila, National Capital Region (PH-00), Philippines (PH).

Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals.  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. 
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
May also perform clinical reviews.
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-rooutine 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. 
Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
Prepare case recommemdations 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
• 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 trusted global innovator of business and technology services. We serve 75% of the Fortune Global 100 and are committed to helping clients innovate, optimize and transform for long term success. As a Global Top Employer, we have diverse experts in more than 50 countries and a robust partner ecosystem of established and start-up companies. Our services include business and technology consulting, data and artificial intelligence, industry solutions, as well as the development, implementation and management of applications, infrastructure and connectivity. We are one of the leading providers of digital and AI infrastructure in the world. NTT DATA is a part of NTT Group, which invests over $3.6 billion each year in R&D to help organizations and society move confidently and sustainably into the digital future. Visit us at us.nttdata.com

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 and @talent.nttdataservices.com email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, https://us.nttdata.com/en/contact-us.

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