BPO Clinical Review Specialist

Req ID: 385834 

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 Specialist to join our team in Florida, Florida (US-FL), United States (US).

 

 

Clinical Reviewer Specialist (LPN)

 

Position Summary

 

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

 

Required Qualifications

 

• 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.

 

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 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 recommend approvals or denials based on established guidelines and determination auth