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.

• Experience performing quality audits in a healthcare, managed care, health plan, or healthcare BPO environment.
• Experience supporting Medicaid appeals and utilization management operations.
• Familiarity with quality management methodologies and continuous improvement practices.

• Required to work U.S. daytime business hours.
• Flexibility may be required based on business and client needs.

• Strong attention to detail and commitment to quality.
• Ability to identify compliance risks and process improvement opportunities.
• Sound clinical judgment and decision-making skills.
• Effective coaching and communication capabilities.
• Commitment to regulatory compliance, member advocacy, and operational excellence.

 

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.