BPO Senior Manager

NTT DATA is seeking a BPO Senior Manager to lead and oversee a team of clinical reviewers supporting the appeals and utilization management process in Florida. This fully remote role requires residency in Florida with a valid address (P.O. boxes are not allowed).

About the role

As the Clinical Reviewer Manager, you will ensure all appeal reviews are completed accurately, timely, and in compliance with state and federal regulations, NCQA standards, organizational policies, and customer requirements. You will serve as a clinical subject matter expert, provide training and coaching, manage team performance, and drive continuous process improvement initiatives to enhance operational efficiency and quality outcomes.

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.

Requirements

• Active, unencumbered Registered Nurse (RN) license required; Florida State-required RN licensure and/or Compact State RN License.
• 5 years of experience in appeals management, utilization management, or clinical review operations.
• 1 year of leadership experience in a supervisory, managerial, or team lead role.
• 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; flexibility may be required based on operational and customer needs.
• Must live in Florida and have a valid address (P.O. boxes are not allowed).
• Must have a working device (such as a cell phone or tablet) for the 2-Factor Authentication process.
• Must pass a drug screen, background check (including education and employment verification).

Skills

• 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.

Benefits

• Medical, dental, and vision insurance with employer contribution.
• Flexible spending or health savings account.
• Life and AD&D insurance.
• Short- and long-term disability coverage.
• Paid time off.
• Employee assistance program.
• 401k program with company match.
• Additional voluntary or legally required benefits.

Pay

$93,600 per year.

Remote Work Requirements

• Must meet all established remote work requirements, including a dedicated, professional workspace conducive to servicing customers with minimal distractions.
• Workspace must be a permanent, unencumbered location used daily for work, ideally isolated from household members and used exclusively for job duties.
• Must provide your 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).
• NTT DATA will provide a computer and headset for remote work; employees are responsible for their care and security and must return them upon separation.
• Must work from the same location consistently unless prior approval is obtained; any relocation must meet all remote workspace and technology requirements.
• Chronic connectivity issues or recurring downtime that impede job performance may result in a change from remote to onsite status.