BPO Clinical Review Specialist

NTT DATA Services•Florida City, FL

2d•$62,150 - $62,150•Remote

About The Position

NTT DATA is seeking a BPO Clinical Review Specialist to join their team in Florida. This role is responsible for performing clinical and medical necessity reviews to support the timely and accurate processing of member and provider appeals. The specialist will evaluate medical records, clinical documentation, and applicable criteria to determine medical necessity and prepare recommendations for Medical Director review. The position 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 fully remote and requires the employee to live in the state of Florida with a valid address. NTT DATA provides a computer and headset for remote work, but employees are responsible for their own high-speed internet access (at or above 50 Mbps) and a hard-wired ethernet connection. A dedicated, professional workspace conducive to servicing customers with minimal distractions is required.

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 Licensed Practical Nurse (LPN) license required. (Not encumbered only)
Florida State-required LPN licensure and/or Compact State LPN 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.

Nice To Haves

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.

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.