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NTT DATA Services

BPO Clinical Review Specialist

FL · On-site

$76K/yr

We are currently seeking a BPO Clinical Review Specialist to join our team in Florida, Florida (US ... Ability to make sound decisions in complex and non-routine appeal situations. * Effective ...

NTT DATA Services

BPO Clinical Review Specialist

FL · On-site

$62K/yr

We are currently seeking a BPO Clinical Review Specialist to join our team in Florida, Florida (US ... Ability to make sound decisions in complex and non-routine appeal situations. * Effective ...

NTT DATA Services

TEMP BPO Associate

Lincoln, RI · On-site +1

We are currently seeking a TEMP BPO Associate to join our team in Lincoln, Rhode Island (US-RI ... This position is full-time, remote (Work at Home), non-exempt, and requires schedule flexibility ...

NTT DATA Services

TEMP BPO Associate

Lincoln, RI · On-site +1

We are currently seeking a TEMP BPO Associate to join our team in Lincoln, Rhode Island (US-RI ... This position is full-time, remote (Work at Home), non-exempt, and requires schedule flexibility ...

NTT DATA Services

TEMP BPO Associate

Lincoln, RI · On-site

We are currently seeking a TEMP BPO Associate to join our team in Lincoln, Rhode Island (US-RI ... This position is full-time, remote (Work at Home), non-exempt, and requires schedule flexibility ...

NTT DATA Services

TEMP BPO Associate

Lincoln, RI · On-site

We are currently seeking a TEMP BPO Associate to join our team in Lincoln, Rhode Island (US-RI ... This position is full-time, remote (Work at Home), non-exempt, and requires schedule flexibility ...

Capgemini

$94 - $263/hr

Success Profile** • Scale a sector-led, BPO-enabled procurement organization across the Americas ... Capgemini offers a comprehensive, non-negotiable benefits package to all regular, full-time ...

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Non Bpo information

What is a non BPO job?

A Non BPO job refers to positions that are not part of the Business Process Outsourcing (BPO) industry. These roles can span various sectors such as IT, healthcare, finance, engineering, education, and more. Unlike BPO jobs, which typically involve customer service or back-office operations outsourced by companies, non BPO jobs involve core business functions and specialized roles. Non BPO jobs often require specific domain knowledge, technical skills, and may offer more opportunities for career advancement within a particular field. They can include both entry-level and experienced positions across many industries.

What are the key skills and qualifications needed to thrive in a non BPO role?

To thrive in a Non-BPO role, you typically need relevant educational qualifications and domain-specific expertise aligned with the industry, such as IT, finance, engineering, or marketing. Familiarity with industry-standard tools, software, and certifications (like SAP for finance, AutoCAD for engineering, or Google Analytics for marketing) is often required. Strong problem-solving abilities, effective communication, and teamwork are essential soft skills that help individuals excel across various functions. These combined skills and qualities are crucial for delivering high-quality work, adapting to organizational needs, and driving business success outside of the BPO sector.

What are some common challenges faced by professionals in non BPO roles within corporate environments?

Professionals in non-BPO (Business Process Outsourcing) roles often face challenges such as adapting to rapidly changing business needs, balancing multiple projects, and collaborating across departments with varying priorities. Unlike BPO roles that may have more defined processes, non-BPO positions can require greater flexibility and initiative to solve unique problems. Additionally, these roles often demand continuous skill development and proactive communication to align with organizational goals and drive career growth.

What is the difference between Non Bpo vs Customer Service Representative?

AspectNon BpoCustomer Service Representative
Work EnvironmentVaries; includes corporate offices, retail, healthcare, etc.Typically call centers, retail stores, or online support
Required SkillsIndustry-specific knowledge, communication skills, problem-solvingCommunication, patience, product knowledge
CertificationsDepends on industry; often no specific Bpo certifications neededCustomer service training, communication courses
Employer & Industry UsageUsed across multiple industries outside Bpo sectorCommonly employed in retail, telecom, banking, and service sectors

Non Bpo roles encompass a wide range of industries and work environments, focusing on specialized skills and industry knowledge. Customer Service Representatives primarily work in support roles within service industries, often in call centers or retail settings. While both roles require strong communication skills, Non Bpo jobs may demand industry-specific certifications and experience, whereas Customer Service roles focus on customer interaction skills.

More about Non Bpo jobs

What job categories do people searching Non Bpo jobs look for?

The top searched job categories for Non Bpo jobs are:

Non Bpo jobs near you
Infographic showing various Non Bpo job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 17% Part Time, 3% Contract, and 1% Nights. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution.

BPO Clinical Review Specialist

NTT DATA Services

FL • On-site

$76K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 15 days ago

Key responsibilities

  • Perform clinical and medical necessity reviews of medical records and documentation to evaluate appeal cases.

  • Research appeal cases, analyze clinical information, and prepare detailed case reviews and recommendations for Medical Directors.

  • Ensure timely review, processing, and resolution of appeals in compliance with policies, regulations, and standards.

NTT Data rating

7.5

Company rating: 7.5 out of 10

Based on 93 frontline employees who took The Breakroom Quiz

110th of 226 rated it services

Job description

Req ID: 385836
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 Specialist to join our team in Florida, Florida (US-FL), United States (US).
Clinical Reviewer Specialist (RN)
Position Summary
The Clinical Reviewer Specialist is responsible for performing clinical and medical necessity reviews to support the timely and accurate processing of member and provider appeals. This role evaluates medical records, clinical documentation, and applicable criteria to determine medical necessity and prepare recommendations for Medical Director review. The Clinical Reviewer Specialist ensures compliance with organizational policies, State and Federal regulations, Medicaid requirements, and NCQA standards while delivering high-quality appeal determinations and communications.
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 $76,000
Required Qualifications
  • 3 years of experience in appeals processing, utilization management, case management, or clinical review operations.
  • Knowledge of utilization management and medical necessity review processes.
  • Understanding of NCQA standards, Medicaid regulations, and healthcare appeals requirements.
  • Strong analytical and critical-thinking skills with the ability to interpret medical records and clinical documentation.
  • Excellent written and verbal communication skills, including strong reading comprehension and documentation abilities.
  • Ability to work independently while managing multiple priorities and deadlines.
  • Strong organizational and problem-solving skills.
  • Proficiency in researching clinical criteria and preparing concise case summaries and recommendations.
  • Experience supporting Medicaid appeals and utilization management programs.
  • Previous experience in a managed care, health plan, healthcare, or healthcare BPO environment.
  • Familiarity with regulatory and accreditation requirements governing appeals and grievance processes.
  • Required to work U.S. daytime business hours.
  • Flexibility may be required based on operational and business needs.
  • Strong clinical assessment and medical necessity review skills.
  • Attention to detail and commitment to quality and compliance.
  • Ability to make sound decisions in complex and non-routine appeal situations.
  • Effective communication and collaboration with internal and external stakeholders.
  • Commitment to timely, accurate, and member-focused appeal resolution.

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
  • Conduct comprehensive clinical reviews of medical records and supporting documentation to evaluate medical necessity for appealed services.
  • Research appeal cases and prepare detailed case reviews for Medical Directors by analyzing clinical information, applicable criteria, and the basis for the appeal.
  • Review claim and service appeals for reconsideration and make recommendations based on established guidelines and determination authority for senior reviewer to make final adjudication of claim approval or denial
  • Prepare case recommendations and supporting documentation for Medical Director review as required.
  • Apply sound clinical judgment when evaluating routine and complex appeal cases.
  • Ensure timely review, processing, and resolution of appeals in accordance with company policies, contractual requirements, State and Federal regulations, Medicaid guidelines, and NCQA standards.
  • Generate accurate appeal determination letters, communications, and reports for members and providers.
  • Maintain complete and accurate appeal records and documentation throughout the review process.
  • Ensure appeal decisions and supporting documentation meet quality and compliance requirements.
  • Communicate effectively with providers, healthcare facilities, Medical Directors, and internal departments regarding appeal requests and supporting clinical information.
  • Collaborate with leadership and operational teams to improve the consistency, accuracy, and appropriateness of appeal review outcomes.
  • Partner with cross-functional teams to identify opportunities for process improvement and enhanced operational performance.
  • Participate in discussions regarding complex cases and escalation reviews.
  • Support initiatives to improve clinical appeals processes, workflows, and service quality.
  • Identify trends and recurring issues within appeals and recommend process improvements based on best practices.
  • Maintain current knowledge of medical necessity guidelines, utilization management practices, Medicaid requirements, and NCQA standards.
  • Contribute to achieving departmental quality, productivity, and turnaround-time objectives.

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 computer and 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 downtime that 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 a dedicated, professional workspace conducive to servicing Customer Service customers with the same quality as an onsite environment.
  • The workspace must be a permanent, unencumbered location used daily for work.
  • Employees must work with minimal distractions that do not interfere with business operations or service delivery.
  • Ideally, the workspace is isolated from other household members and used exclusively for job duties.
  • Background noise, interruptions from people or pets, and other distractions must be kept to an absolute minimum to avoid disruptions to customer service.
  • Employees must work from the same location consistently unless prior approval is obtained.
  • If a change in work location is necessary:
  • The new location must meet all Remote Workspace and Technology Requirements.
  • Notification to NTT DATA Management is required before relocating

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, https://us.nttdata.com/en/contact-us.
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. If you'd like more information on your EEO rights under the law, please click here. For Pay Transparency information, please click here.

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About NTT DATA

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NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.

Industry

It services

Company size

10,000+ Employees

Headquarters location

Plano, TX, US

Year founded

1967

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