BPO Clinical Review Senior Specialist

NTT DATA Services•Jacksonville, FL

2d•$81,120 - $81,120•Remote

About The Position

NTT DATA is seeking a BPO Clinical Review Senior Specialist to join their team in Jacksonville, Florida. This role is responsible for conducting quality audits of clinical appeal reviews and providing subject matter expertise to ensure accurate and timely processing of member and provider appeals. The position evaluates clinical reviews, medical records, and appeal determinations for compliance with organizational policies, regulatory requirements, Medicaid guidelines, and NCQA standards. The QA Analyst partners with operations leadership to improve quality, consistency, and operational effectiveness across the appeals review process. This position is fully remote and requires the candidate to live in the state of Florida.

Requirements

3 years of experience in appeals processing, clinical review, or utilization management.
1 year of experience in an advanced role as: Quality Analyst (QA), Team Lead, Trainer, or Subject Matter Expert (SME).
Strong knowledge of utilization management and appeals processes.
Working knowledge of NCQA standards, Medicaid regulations, and medical necessity review guidelines.
Ability to review and interpret medical records and clinical documentation.
Excellent analytical, critical thinking, and problem-solving skills.
Strong written and verbal communication skills, including reading comprehension and professional documentation.
Ability to provide constructive feedback and influence quality improvement initiatives.
Strong organizational skills with the ability to manage multiple priorities independently.
Proficiency in conducting audits, identifying trends, and presenting findings.
Experience performing quality audits in a healthcare, managed care, health plan, or healthcare BPO environment.
Experience supporting Medicaid appeals and utilization management operations.
Familiarity with quality management methodologies and continuous improvement practices.
Required to work U.S. daytime business hours.
Flexibility may be required based on business and client needs.
Strong attention to detail and commitment to quality.
Ability to identify compliance risks and process improvement opportunities.
Sound clinical judgment and decision-making skills.
Effective coaching and communication capabilities.
Commitment to regulatory compliance, member advocacy, and operational excellence.
Active Licensed Practical Nurse (LPN) license required. (Not encumbered only)
Florida State-required LPN licensure and/or Compact State LPN License required. (Not encumbered only)
Must have a working device (such as cell phone or tablet) for the 2-Factor Authentication process.
Must Pass Drug screen.
Must Pass a background check with Education check and employment verification check.
Employees must provide their own high speed internet access with speeds at or above 50 Mbps.
A hard-wired ethernet connection is required. Wi-Fi, mobile, wireless and public internet connections are forbidden as are connections outside of one’s personal dwelling or location.

Nice To Haves

Experience performing quality audits in a healthcare, managed care, health plan, or healthcare BPO environment.
Experience supporting Medicaid appeals and utilization management operations.
Familiarity with quality management methodologies and continuous improvement practices.

Responsibilities

Conduct quality audits of clinical appeals reviews to ensure accuracy, consistency, and compliance with established standards.
Evaluate medical records, clinical documentation, and appeal determinations to assess adherence to medical necessity criteria and utilization management guidelines.
Identify quality trends, defects, and opportunities for improvement within the appeals process.
Provide feedback, coaching, and corrective action recommendations to team members based on audit findings.
Support quality calibration sessions and contribute to the development of quality improvement initiatives.
Serve as a subject matter expert (SME) on appeals processing, utilization management, and medical necessity review.
Provide guidance to Clinical Reviewers on preparing cases for Medical Director review, including researching appeals, reviewing applicable criteria, and analyzing supporting documentation.
Review service appeals for reconsideration and recommend approvals or denials based on established determination guidelines.
Prepare complex cases for Medical Director review when required.
May perform clinical reviews and appeal determinations as needed to support operational demands.
Ensure appeal reviews and determinations comply with State, Federal, Medicaid, and NCQA requirements.
Verify timely review, processing, and resolution of appeal requests in accordance with contractual and regulatory turnaround times.
Generate and review appeal resolution communications to members and providers for accuracy, completeness, and compliance.
Maintain thorough documentation and audit records related to appeal reviews and quality evaluations.
Communicate with providers, facilities, Medical Directors, and internal departments regarding appeal reviews and determinations.
Partner with leadership to improve the consistency, quality, efficiency, and appropriateness of appeal review decisions.
Collaborate with cross-functional teams to identify and implement process improvements based on industry best practices.
Analyze quality findings and provide recommendations to prevent recurring issues and enhance operational performance.
Maintain files and records for appeal reviews, including the collection, analysis, and reporting of verbal and written member and provider appeals.
Track quality metrics and contribute to performance reporting and quality dashboards.
Utilize sound clinical judgment in evaluating non-routine and complex appeals while ensuring compliance with service-level agreements and contractual requirements.