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BlueCross BlueShield of Tennessee · 7 hours ago

Behavioral Health Clinical Review Manager

United States

Full-time

Remote

Mid Level

3+ years exp

BlueCross BlueShield of Tennessee is focused on making a meaningful impact on individuals facing mental health challenges. The Behavioral Health Clinical Review Manager plays a critical role in shaping care decisions and improving outcomes in a remote setting.

Health CareMedical

Responsibilities

Assists non-clinical staff in performance of administrative reviews

Initiate referrals to ensure appropriate coordination of care

Seek the advice of the Medical Director when appropriate, according to policy

Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility

Various immunizations and/or associated medical tests may be required for this position

Qualification

Behavioral HealthUtilization ManagementSubstance Use TreatmentCommunity Care ResourcesMicrosoft OfficeAnalytical SkillsCommunication SkillsDecision-Making SkillsInterpersonal SkillsOrganizational SkillsRelationship BuildingTime ManagementAdaptability

Required

Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above) (Ph.D., LCSW/LMSW, LLP, MHC, LPC, etc.) required

3 years - Clinical behavioral health / substance use disorder experience required

Must be knowledgeable about community care resources and levels of behavioral health care available

Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)

Independent, Sound decision-making and problem-solving skills

Excellent oral and written communication skills

Strong interpersonal and organizational skills

Strong analytical skills

Positive relationship building skills and ability to engage with diverse populations

Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions