BPO Clinical Review Specialist

Job Title: BPO Clinical Review Specialist (Location: Manila, National Capital Region, Philippines)

Roles and Responsibilities

• 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.
• Has a well‑ro...