BPO Clinical Review Specialist Job at NTT DATA, Inc., Philippines

TlJYN3dkWmorNGQ3SGhuRExpNVN5dnpFdlE9PQ==
  • NTT DATA, Inc.
  • Philippines

Job Description

"Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Roles and Responsibilities:

Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.

Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.

Communicates with providers, facilities and other departments regarding appeal requests.

Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards.

Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests.

Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.

Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review.

Uses sound judgement, especially in non-rooutine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards.

Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals.

Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.

Prepare case recommemdations for medical review as necessary.

1-3 years of experience in processing appeals or utilization management.

RN - Registered Nurse - State required Licensure and/or Compact State Licensure

Knowledge of utilization management process

Knowledge of NCQA, Medicaid requlations

Good communication (Demonstrate strong reading comprehension and writing skills)

Able to work independently, strong analytic skills

Required shift timings - US daytime"

Job Tags

Shift work,

Similar Jobs

Mercedes - Benz Of Alexandria

New Car Sales Associate Job at Mercedes - Benz Of Alexandria

 ...our growing client base. If you are a successful, professional car sales consultant looking to upgrade your compensation, benefits...  ...represent the finest cars and SUVs offered, than this is the dealership for you. We are a family of Mercedes-Benz enthusiasts warmly serving... 

Bristol Myers Squibb

Manufacturing Associate, Cell Therapy in Devens, MA Job at Bristol Myers Squibb

 ...programs that provide our employees with the resources to pursue their goals, both at work and in their personal lives. Read more: careers.bms.com/working-with-us . At Bristol Myers Squibb we are reimagining the future of cell therapy. With our bold ambition, backed by a... 

Compass Group

PATIENT TRANSPORTER (PART TIME) Job at Compass Group

 ...are hiring immediately for part time PATIENT TRANSPORTER positions. Address : Henry...  ...upon interview. Requirement : No experience required. Fixed Pay Rate: $15.00...  ...effectively with nursing personnel, clinicians, technicians or reception and dispatch. Ensures... 

Arrow Truckers LLC

Flatbed Hotshot Owner Operators - Home Weekly or 4-Week OTR | $4K-$6K Take Home Job at Arrow Truckers LLC

 ...Take-home Job Summary: We are hiring Flatbed Hotshot Owner Operators (CDL & Non-CDL) with their own truck and trailer. This position offers home weekly or long-term OTR options, strong weekly earnings, and full dispatch, compliance, and operational support. Owner... 

The IVF Guide

Fertility Nurse Practitioner for senior role in IVF clinic, WA State Job at The IVF Guide

 ...Job Title: Fertility Nurse Practitioner in an IVF/Reproductive Medicine Center Location: Bellingham, WA Position Overview...  ...will have experience in reproductive endocrinology or womens health and a strong desire to provide personalized, empathetic care to...