[Hiring] Utilization Review Medical Appeals Nurse @NTT DATA Services

Role Description

We are currently seeking a Utilization Review Medical Appeals Nurse - USRN to join our team in Manila, Quezon (PH-QUE), Philippines (PH). In this role, you will be responsible for:

• Performing 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.
• Preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensuring timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicating with providers, facilities and other departments regarding appeal requests.
• Generating appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Working with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests.
• Partnering with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Having a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review.
• Using sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards.
• Maintaining files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals.
• Reviewing claim appeal for reconsideration and recommending approvals/denials based on determination level or preparing for medical review presentation.
• Preparing case recommendations for medical review as necessary.

Qualifications

• 1-3 years of experience in processing appeals or utilization management.
• US Registered Nurse (USRN)
• 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
• Can work remotely

Company Description

NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services.

• Our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future.
• As a Global Top Employer, we have experts in more than 50 countries.
• We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners.
• NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D.