Hiring: BPO Clinical Review Specialist Company: NTT DATA North America Location: Tampa, FL Job Posted Time: 2026-09-11 12:15:43 Employment Type: Remote Target Skills & Keywords : AI, Accessibility, Clinical Documentation, Medicaid, R About the job Experience: •3 years of experience in appeals processing, utilization management, case management, or clinical review operations. Required Skills: •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 $76,000 •Conduct comprehensive clinical reviews of medical records and supporting documentation to evaluate medical necessity for appealed services. •Research appeal cases and prepare detailed case reviews for Medical Directors by analyzing clinical information, applicable criteria, and the basis for the appeal. •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 case recommendations and supporting documentation for Medical Director review as required. •Ensure timely review, processing, and resolution of appeals in accordance with company policies, contractual requirements, State and Federal regulations, Medicaid guidelines, and NCQA standards. •Generate accurate appeal determination letters, communications, and reports for members and providers. Qualifications: •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. •Demonstrated capacity 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. •Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment. •Operational familiarity with regulatory and accreditation requirements governing appeals and grievance processes. •Required to work U.S. daytime business hours. Compensation: •Flexible work environment (work from home / hybrid options) Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!