BPO Clinical Review Specialist

NTT DATA Services•Tempa, WV

16h•Remote

About The Position

The Clinical Reviewer Specialist conducts clinical and medical necessity reviews to support timely, accurate processing of member and provider appeals. The role evaluates medical records, clinical documentation, and applicable criteria, then prepares recommendations for Medical Director review. It ensures compliance with organizational policies, State and Federal regulations, Medicaid requirements, and NCQA standards while producing high-quality appeal determinations and communications. This is a fully remote position available only to candidates who live in Florida and have a valid Florida address; P.O. Boxes are not accepted. The role requires U.S. daytime business hours, with flexibility as operational and business needs require. The salary is $76,000. The company provides a computer and headset. Employees must provide high-speed internet of at least 50 Mbps and use a hard-wired Ethernet connection from their personal dwelling. A dedicated, permanent, professional workspace with minimal distractions is required. Employees must have a working device, such as a cell phone or tablet, for two-factor authentication. Candidates must pass a drug screen and background check, including education and employment verification. The position requires an active, unencumbered RN license and Florida-required and/or Compact State RN licensure.

Requirements

At least 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, including the ability to interpret medical records and clinical documentation.
Excellent written and verbal communication, reading comprehension, and documentation skills.
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.
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, unencumbered Registered Nurse (RN) license.
Florida State-required RN licensure and/or a Compact State RN License, unencumbered.
Must live in Florida and have a valid address; P.O. Boxes are not accepted.
Must work U.S. daytime business hours; flexibility may be required based on operational and business needs.
Must have a working device, such as a cell phone or tablet, for two-factor authentication.
Must pass a drug screen and a background check that includes education and employment verification.
For remote work, must provide high-speed internet with speeds of at least 50 Mbps and a hard-wired Ethernet connection; Wi-Fi, mobile, wireless, public, and connections outside the employee’s personal dwelling or location are forbidden.
Must maintain a dedicated, permanent professional workspace with minimal distractions and work consistently from the same location unless prior approval is obtained.
Must comply with remote-work technology, workspace, technical-support, and equipment-security requirements.

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 outcomes based on established guidelines and determination authority for a senior reviewer to make the final adjudication of claim approval or denial.
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 with providers, healthcare facilities, Medical Directors, and internal departments about 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 process-improvement opportunities and enhance 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 departmental quality, productivity, and turnaround-time objectives.