BPO Clinical Review Specialist

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.  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.
Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment.
Familiarity with regulatory and accreditation requirements governing appeals and grievance processes.
Strong clinical assessment and medical necessity review skills.
Attention to detail and commitment to quality and compliance.
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 make recommendations based on established guidelines and determination authority for senior reviewer to make final adjudication of claim approval or denial
Prepare case recommendations and supporting documentation for Medical Director review as required.
Ensure timely review, processing, and resolution of appeals in accordance with company policies, contractual requirements, State and Federal regulations, Medicaid guidelines, and NCQA standards.
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.
Partner with cross-functional teams to identify opportunities for process improvement and enhanced operational performance.
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.

New hire must have a working device (such as cell phone or tablet) for the 2-Factor Authentication process

Applications are pre-screened using artificial intelligence technology and reviewed by NTT DATA recruiters.

NTT Data does not allow Job stacking

Remote Working and Technology Requirements

To work remote, individuals must meet all the established Remote requirements including those pertaining to a home workspace and related technology.
NTT DATA will provide a computer and headset for remote work.
Employees are responsible for the care and security of all equipment provided. They must return it immediately upon separation from the company following company protocols.
Failure to return equipment may result in collection actions and/or other consequences.
Wi-Fi, mobile, wireless and public internet connections are forbidden as are connections outside of one’s personal dwelling or location.

Technical Performance and Issue Tracking

Consistent availability is critical to business operations.
Remote employees must adhere to all technical support procedures and protocols.
Chronic connectivity issues or recurring downtime that impede job performance, including internet outages, may result in the remote status changing to onsite.

Remote Workspace

Remote work demands a high degree of professionalism, self-discipline, and accountability. 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.
Background noise, interruptions from people or pets, and other distractions must be kept to an absolute minimum to avoid disruptions to customer service.
The new location must meet all Remote Workspace and Technology Requirements.
Notification to NTT DATA Management is required before relocating

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