BPO Clinical Review Specialist

Req

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,

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

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. P.O Boxes will not be allowed.

Salary for this role is $62,150

• 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.
• Excellent written and verbal communication skills, including strong reading comprehension and documentation abilities.
• Ability to work independently while managing multiple priorities and deadlines.
• Strong organizational and problem-solving skills.
• Proficiency in researching clinical criteria and preparing concise case summaries and recommendations.
• Experience supporting Medicaid appeals and utilization management programs.
• Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment.
• Familiarity with regulatory and accreditation requirements governing appeals and grievance processes.
• Required to work U.S. daytime business hours.
• Flexibility may be required based on operational and business needs.
• Strong clinical assessment and medical necessity review skills.
• Attention to detail and commitment to quality and compliance.
• Ability to make sound decisions in complex and non-routine appeal situations.
• Effective communication and collaboration with internal and external stakeholders.
• Commitment to timely, accurate, and member-focused appeal resolution.

• 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)

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

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.
• 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.

• Management monitors all technical issues and agent downtime. Consistent…