BPO Clinical Review Senior Specialist

Req ID: 385874

NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.

We are currently seeking a BPO Clinical Review Senior Specialist to join our team in Jacksonville, Florida (US-FL), United States (US).

The Clinical Reviewer Quality Analyst (QA) is responsible for conducting quality audits of clinical appeal reviews and providing subject matter expertise to support the accurate and timely processing of member and provider appeals. This role evaluates clinical reviews, medical records, and appeal determinations to ensure compliance with organizational policies, regulatory requirements, Medicaid guidelines, and NCQA standards. The QA Analyst partners with operations leadership to improve quality, consistency, and operational effectiveness across the appeals review process.

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 $81,120

Required Qualifications

• 3 years of experience in appeals processing, clinical review, or utilization management.
• 1 year of experience in an advanced role as:
• Quality Analyst (QA)
• Team Lead
• Trainer
• Subject Matter Expert (SME)

• Strong knowledge of utilization management and appeals processes.
• Working knowledge of NCQA standards, Medicaid regulations, and medical necessity review guidelines.
• Ability to review and interpret medical records and clinical documentation.
• Excellent analytical, critical thinking, and problem-solving skills.
• Strong written and verbal communication skills, including reading comprehension and professional documentation.
• Ability to provide constructive feedback and influence quality improvement initiatives.
• Strong organizational skills with the ability to manage multiple priorities independently.
• Proficiency in conducting audits, identifying trends, and presenting findings.

• Experience performing quality audits in a healthcare, managed care, health plan, or healthcare BPO environment.
• Experience supporting Medicaid appeals and utilization management operations.
• Familiarity with quality management methodologies and continuous improvement practices.

• Required to work U.S. daytime business hours.
• Flexibility may be required based on business and client needs.

• Strong attention to detail and commitment to quality.
• Ability to identify compliance risks and process improvement opportunities.
• Sound clinical judgment and decision-making skills.
• Effective coaching and communication capabilities.
• Commitment to regulatory compliance, member advocacy, and operational excellence.

Education & Licensure

• 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)

Key Responsibilities

• Conduct quality audits of clinical appeals reviews to ensure accuracy, consistency, and compliance with established standards.
• Evaluate medical records, clinical documentation, and appeal determinations to assess adherence to medical necessity criteria and utilization management guidelines.
• Identify quality trends, defects, and opportunities for improvement within the appeals process.
• Provide feedback, coaching, and corrective action recommendations to team members based on audit findings.
• Support quality calibration sessions and contribute to the development of quality improvement initiatives.

• Serve as a subject matter expert (SME) on appeals processing, utilization management, and medical necessity review.
• Provide guidance to Clinical Reviewers on preparing cases for Medical Director review, including researching appeals, reviewing applicable criteria, and analyzing supporting documentation.
• 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 complex cases for Medical Director review when required.
• May perform clinical reviews and appeal determinations as needed to support operational demands.

• Ensure appeal reviews and determinations comply with State, Federal, Medicaid, and NCQA requirements.
• Verify timely review, processing, and resolution of appeal requests in accordance with contractual and regulatory turnaround times.
• Generate and review appeal resolution communications to members and providers for accuracy, completeness, and compliance.
• Maintain thorough documentation and audit records related to appeal reviews and quality evaluations.

• Communicate with providers, facilities, Medical Directors, and internal departments regarding appeal reviews and determinations.
• Partner with leadership to improve the consistency, quality, efficiency, and appropriateness of appeal review decisions.
• Collaborate with cross-functional teams to identify and implement process improvements based on industry best practices.
• Analyze quality findings and provide recommendations to prevent recurring issues and enhance operational performance.

• Maintain files and records for appeal reviews, including the collection, analysis, and reporting of verbal and written member and provider appeals.
• Track quality metrics and contribute to performance reporting and quality dashboards.
• Utilize sound clinical judgment in evaluating non-routine and complex appeals while ensuring compliance with service-level agreements and contractual requirements.

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.

This job posting is for active vacancies. 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.

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.
• 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.

Technical Performance and Issue Tracking

• Management monitors all technical issues and agent downtime. 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. The following workspace standards are vital to delivering exceptional service.

• 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.
• Ideally, the workspace is isolated from other household members and used exclusively for job duties.
• Background noise, interruptions from people or pets, and other distractions must be kept to an absolute minimum to avoid disruptions to customer service.
• Employees must work from the same location consistently unless prior approval is obtained.
• If a change in work location is necessary:

• The new location must meet all Remote Workspace and Technology Requirements.
• Notification to NTT DATA Management is required before relocating

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About NTT DATA

NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D.

Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client’s needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. NTT DATA recruiters will never ask for payment or banking information and will only use @nttdata.com, @nttdatafed.com and @talent.nttdataservices.com email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, 

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