Req ID:385869
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 Senior Manager to join our team in Tampa, Florida (US-FL), United States (US).
The Clinical Reviewer Manager is responsible for leading and overseeing a team of clinical reviewers supporting the appeals and utilization management process. This role ensures all appeal reviews are completed accurately, timely, and in compliance with state and federal regulations, NCQA standards, organizational policies, and customer requirements. The manager serves as a clinical subject matter expert, provides training and coaching, manages team performance, and drives continuous process improvement initiatives to enhance operational efficiency and quality outcomes.
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 $93,600
Required Qualifications
- 5 years of experience in appeals management, utilization management, or clinical review operations.
- 1 year of leadership experience in a supervisory, managerial, team lead
- Experience managing teams in a healthcare, managed care, health plan, or utilization management environment preferred.
- Strong knowledge of utilization management and appeals processes.
- In-depth understanding of NCQA standards, Medicaid regulations, and medical necessity review requirements.
- Demonstrated expertise in reviewing medical records and clinical documentation.
- Strong analytical and critical-thinking skills with the ability to make sound decisions in complex situations.
- Excellent written and verbal communication skills, including strong reading comprehension and documentation abilities.
- Ability to work independently while effectively leading and influencing team performance.
- Proficiency in performance tracking, reporting, and operational management.
- Experience supporting Medicaid populations and government-sponsored healthcare programs.
- Prior experience managing clinical appeals teams in a health plan, managed care organization, or healthcare BPO environment.
- Experience implementing process improvement initiatives and quality management programs.
- Must be available to work during U.S. daytime business hours.
- May require flexibility based on operational and customer needs.
- Strong leadership and people management skills.
- Commitment to quality, compliance, and member advocacy.
- Ability to balance clinical judgment with regulatory and contractual requirements.
- Focus on continuous improvement, operational excellence, and customer satisfaction.
Education & Licensure
- Active Registered Nurse (RN) license required. (Not encumbered only)
- Florida State-required RN licensure and/or Compact State RN License required. (Not encumbered only)
Key Responsibilities
- Lead, coach, and develop a team of Clinical Reviewers responsible for appeals and utilization management activities.
- Serve as a subject matter expert (SME) and provide training, mentorship, and guidance on clinical review processes, medical necessity determinations, and appeals management.
- Monitor and evaluate team performance, productivity, quality, and compliance with established standards and service-level agreements.
- Allocate and manage case assignments to ensure balanced workloads and adherence to turnaround times.
- Collaborate with customers and internal stakeholders to ensure operational standards and performance expectations are met.
- Provide ongoing feedback, performance management, and development opportunities for team members.
- Ensure the team effectively prepares comprehensive case reviews for Medical Directors by:
- Researching appeal cases.
- Reviewing medical records and clinical documentation.
- Evaluating applicable medical necessity criteria.
- Analyzing the basis and supporting evidence for appeals.
- Oversee the timely and accurate processing of member and provider appeals.
- Ensure appeal determinations and responses comply with contractual, regulatory, and accreditation requirements.
- Support complex and non-routine appeals by applying sound clinical judgment and decision-making.
- Ensure all appeals reviews are conducted according to organizational policies, clinical guidelines, regulatory requirements, and NCQA standards.
- Maintain oversight of compliance with Medicaid regulations and utilization management requirements.
- Monitor quality metrics and reporting standards while identifying opportunities for improvement.
- Ensure accurate documentation and maintenance of appeal files, including collection, analysis, and reporting of verbal and written appeal information.
- Track, analyze, and report team performance metrics, productivity, quality outcomes, and compliance measures.
- Partner with leadership to improve consistency, efficiency, and appropriateness of appeal review processes and responses.
- Collaborate with cross-functional teams to enhance clinical appeals procedures and implement best practices that reduce recurrence of issues.
- Identify operational challenges and recommend process improvements to strengthen service delivery and regulatory compliance.
New hire must have a working device (such as cell phone or tablet) for the 2-Factor Authentication process
Must Pass Drug screen
Must Pass a background check with Education check and employment verification check.
This job posting is for active vacancies. Applications are pre-screened using artificial intelligence technology and reviewed by NTT DATA recruiters.
NTT Data does not allow Job stacking
Remote Working and Technology Requirements
To work remote, individuals must meet all the established Remote requirements including those pertaining to a home workspace and related technology.
Technology
- NTT DATA will provide a computerand headset for remote work.
- Employees are responsible for the care and security of all equipment provided. They must return it immediately upon separation from the company following company protocols.
- Failure to return equipment may result in collection actions and/or other consequences.
- Individuals must provide their own high speed internet access with speeds at or above 50 Mbps.
- A hard-wired ethernet connection is required. Wi-Fi, mobile, wireless and public internet connections are forbidden as are connections outside of one?s personal dwelling or location.
Technical Performance and Issue Tracking
- Management monitors all technical issues and agent downtime. Consistent availability is critical to business operations.
- Remote employees must adhere to all technical support procedures and protocols.
- Chronic connectivity issues or recurring downtimethat impede job performance, including internet outages, may result in the remote status changing to onsite.
Remote Workspace
Remote work demands a high degree of professionalism, self-discipline, and accountability. The following workspace standards are vital to delivering exceptional service.
- Employees must have adedicated, professional workspaceconducive to servicing Customer Service customers with the same quality as an onsite environment.
- The workspace must be apermanent, unencumbered locationused daily for work.
- Employees must work withminimal distractionsthat do not interfere with business operations or service delivery.
- Ideally, the workspace isisolated from other household membersand used exclusively for job duties.
- Background noise, interruptions from people or pets, and other distractionsmust be kept to an absolute minimum to avoid disruptions to customer service.
- Employees must work from thesame location consistentlyunless prior approval is obtained.
- If a change in work location is necessary:
- The new location must meet allRemote Workspace and Technology Requirements.
- Notification to NTT DATA Managementis required before relocating
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About NTT DATA
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.
Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client?s needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. NTT DATA recruiters will never ask for payment or banking information and will only use @nttdata.com, @nttdatafed.com and @talent.nttdataservices.com email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form,.
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