BPO Clinical Review Specialist

NTT DATA Services•Jacksonville, FL

2d•Remote

About The Position

The Clinical Reviewer Specialist is responsible for performing clinical and medical necessity reviews to support the timely and accurate processing of member and provider appeals. This role evaluates medical records, clinical documentation, and applicable criteria to determine medical necessity and prepare recommendations for Medical Director review. The Clinical Reviewer Specialist ensures compliance with organizational policies, State and Federal regulations, Medicaid requirements, and NCQA standards while delivering high-quality appeal determinations and communications. This position is eligible for company benefits including medical, dental, and vision insurance with an employer contribution, flexible spending or health savings account, life and AD&D insurance, short- and long-term disability coverage, paid time off, employee assistance, participation in a 401k program with company match, and additional voluntary or legally required benefits. Position is fully remote only in the state of Florida. Must live in State of Florida and have a valid address. P.O Boxes will not be allowed. Salary for this role is $76,000

Requirements

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.
Active Registered Nurse (RN) license required. (Not encumbered only)
Florida State-required RN licensure and/or Compact State RN License required. (Not encumbered only)
New hire 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.
Individuals 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.
Employees must have a dedicated, professional workspace conducive to servicing Customer Service customers with the same quality as an onsite environment.
The workspace must be a permanent, unencumbered location used daily for work.
Employees must work with minimal distractions that do not interfere with business operations or service delivery.
Ideally, the workspace is isolated from other household members and used exclusively for job duties.
Background noise, interruptions from people or pets, and other distractions must be kept to an absolute minimum to avoid disruptions to customer service.
Employees must work from the same location consistently unless prior approval is obtained.

Nice To Haves

Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment.

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 recommend approvals or denials based on established guidelines and determination authority.
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.