BPO Senior Manager

NTT DATA Services•Florida City, FL

2d•$93,600 - $93,600•Remote

About The Position

The Clinical Reviewer Manager is responsible for leading and overseeing a team of clinical reviewers supporting the appeals and utilization management process. This role ensures all appeal reviews are completed accurately, timely, and in compliance with state and federal regulations, NCQA standards, organizational policies, and customer requirements. The manager serves as a clinical subject matter expert, provides training and coaching, manages team performance, and drives continuous process improvement initiatives to enhance operational efficiency and quality outcomes. 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 $93,600

Requirements

5 years of experience in appeals management, utilization management, or clinical review operations.
1 year of leadership experience in a supervisory, managerial, team lead
Strong knowledge of utilization management and appeals processes.
In-depth understanding of NCQA standards, Medicaid regulations, and medical necessity review requirements.
Demonstrated expertise in reviewing medical records and clinical documentation.
Strong analytical and critical-thinking skills with the ability to make sound decisions in complex situations.
Excellent written and verbal communication skills, including strong reading comprehension and documentation abilities.
Ability to work independently while effectively leading and influencing team performance.
Proficiency in performance tracking, reporting, and operational management.
Must be available to work during U.S. daytime business hours.
May require flexibility based on operational and customer needs.
Strong leadership and people management skills.
Commitment to quality, compliance, and member advocacy.
Ability to balance clinical judgment with regulatory and contractual requirements.
Focus on continuous improvement, operational excellence, and customer satisfaction.
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.

Nice To Haves

Experience managing teams in a healthcare, managed care, health plan, or utilization management environment preferred.
Experience supporting Medicaid populations and government-sponsored healthcare programs.
Prior experience managing clinical appeals teams in a health plan, managed care organization, or healthcare BPO environment.
Experience implementing process improvement initiatives and quality management programs.

Responsibilities

Lead, coach, and develop a team of Clinical Reviewers responsible for appeals and utilization management activities.
Serve as a subject matter expert (SME) and provide training, mentorship, and guidance on clinical review processes, medical necessity determinations, and appeals management.
Monitor and evaluate team performance, productivity, quality, and compliance with established standards and service-level agreements.
Allocate and manage case assignments to ensure balanced workloads and adherence to turnaround times.
Collaborate with customers and internal stakeholders to ensure operational standards and performance expectations are met.
Provide ongoing feedback, performance management, and development opportunities for team members.
Ensure the team effectively prepares comprehensive case reviews for Medical Directors by: Researching appeal cases, Reviewing medical records and clinical documentation, Evaluating applicable medical necessity criteria, Analyzing the basis and supporting evidence for appeals.
Oversee the timely and accurate processing of member and provider appeals.
Ensure appeal determinations and responses comply with contractual, regulatory, and accreditation requirements.
Support complex and non-routine appeals by applying sound clinical judgment and decision-making.
Ensure all appeals reviews are conducted according to organizational policies, clinical guidelines, regulatory requirements, and NCQA standards.
Maintain oversight of compliance with Medicaid regulations and utilization management requirements.
Monitor quality metrics and reporting standards while identifying opportunities for improvement.
Ensure accurate documentation and maintenance of appeal files, including collection, analysis, and reporting of verbal and written appeal information.
Track, analyze, and report team performance metrics, productivity, quality outcomes, and compliance measures.
Partner with leadership to improve consistency, efficiency, and appropriateness of appeal review processes and responses.
Collaborate with cross-functional teams to enhance clinical appeals procedures and implement best practices that reduce recurrence of issues.
Identify operational challenges and recommend process improvements to strengthen service delivery and regulatory compliance.