BPO Senior Manager

BPO Senior Manager

NTT DATA Services is looking for a BPO Senior Manager to join their team in Tampa, Florida (US-FL), United States. 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.

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.

Required Qualifications:

• 5 years of experience in appeals management, utilization management, or clinical review operations.
• 1 year of leadership experience in a supervisory, managerial, team lead
• Experience managing teams in a healthcare, managed care, health plan, or utilization management environment preferred.
• 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.
• 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.
• 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.

Education & Licensure:

• Active Registered Nurse (RN) license required. (Not encumbered only)
• Florida State-required RN licensure and/or Compact State RN License required. (Not encumbered only)

Key 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.

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.