**Req ID:** 322368 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 Medical Records Specialist to join our team in Manila, National Capital Region (PH-00), Philippines (PH). Grade 5 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. 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 members, providers, facilities, and other departments regarding appeals 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 appeals requests • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices • Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically Medicare and medical necessity review. • Uses sound judgment, 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: • 2 - 4 years of experience in processing appeals or utilization management • RN - Registered Nurse – State required Licensure and/or Compact State Licensure • Knowledge of utilization management processes • Knowledge of NCQA, Medicare and Medicaid regulations • Good communication (Demonstrate strong reading comprehension and writing skills) • Able to work independently, strong analytic skills Required shift timings: US daytime **About NTT DATA** NTT DATA is a $30 billion trusted global innovator of business and technology services. We serve 75% of the Fortune Global 100 and are committed to helping clients innovate, optimize and transform for long term success. As a Global Top Employer, we have diverse experts in more than 50 countries and a robust partner ecosystem of established and start-up companies. Our services include business and technology consulting, data and artificial intelligence, industry solutions, as well as the development, implementation and management of applications, infrastructure and connectivity. We are one of the leading providers of digital and AI infrastructure in the world. NTT DATA is a part of NTT Group, which invests over $3.6 billion each year in R&D to help organizations and society move confidently and sustainably into the digital future. Visit us at us.nttdata.com (http://us.nttdata.com/en) **_NTT DATA endeavors to make_** **_https://us.nttdata.com_** **_accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at_** **_https://us.nttdata.com/en/contact-us_** **_._** **_This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. NTT DATA is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here (http://us.nttdata.com/en/compliance#eeos) . If you'd like more information on your EEO rights under the law, please click here (http://us.nttdata.com/en/compliance#know-your-rights) . For Pay Transparency information, please click here (http://us.nttdata.com/en/compliance#ppnp) ._**