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.

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 service appeals for reconsideration and recommend approvals or denials based on established determination guidelines.
• 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.

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.

Technical Performance and Issue Tracking

Management monitors all technical issues and agent downtime. Consistent availability is critical to business operations.

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.

Employees must work from the same location consistently unless prior approval is obtained.