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Clinical Reviewer Specialist

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NTT DATA

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Location:
Philippines , Manila

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Contract Type:
Not provided

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Salary:

Not provided

Job Description:

The Clinical Reviewer Specialist role involves performing clinical reviews to resolve appeals by analyzing medical records and clinical data. Candidates should have 1-3 years of experience in utilization management and hold a Registered Nurse license. Strong communication and analytical skills are essential for success in this position. Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Job Responsibility:

  • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
  • Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
  • Communicates with providers, facilities and other departments regarding appeal requests
  • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
  • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests
  • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
  • Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards
  • Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals
  • Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation
  • Prepare case recommendations for medical review as necessary

Requirements:

  • 1-3 years of experience in processing appeals or utilization management
  • RN - Registered Nurse - State required Licensure and/or Compact State Licensure
  • Knowledge of utilization management process
  • Knowledge of NCQA, Medicaid regulations
  • Good communication (Demonstrate strong reading comprehension and writing skills)
  • Able to work independently, strong analytic skills
  • Required shift timings - US daytime

Additional Information:

Job Posted:
February 16, 2026

Employment Type:
Fulltime
Work Type:
On-site work
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