BlueCross BlueShield of Tennessee · 1 day ago
Clinical Review Manager FEP
United States
Full-time
Remote
Mid Level
3+ years expBlueCross BlueShield of Tennessee is seeking a Clinical Review Nurse to support the Federal Employee Program (FEP). This role involves conducting comprehensive clinical reviews of medical service requests and supporting utilization management activities such as pre-certifications and appeals.
Health CareMedical
Responsibilities
Initiate referrals to ensure appropriate coordination of care
Seek the advice of the Medical Director when appropriate, according to policy
Assists non-clinical staff in performance of administrative reviews
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
Qualification
Required
Active Registered Nurse (RN) license in the state of Tennessee or a compact state participating in the Nurse Licensure Compact (NLC)
Minimum of 3 years of clinical experience required
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Working knowledge of URAC, NCQA and CMS accreditations
Must be able to work in an independent and creative manner
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Superior interpersonal, client relations and problem-solving skills
Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria
Preferred
Strong critical thinking and clinical decision-making skills
Knowledge of utilization management, appeals, and medical review processes
Familiarity with medical coding standards
Ability to manage workflows across multiple platforms
Company
BlueCross BlueShield of Tennessee
As Tennessee's largest health plan, we've been helping Tennesseans find their own unique paths to good health for more than 70 years.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Casey Dungan
President and Chief Executive Officer - BlueCare
Melissa Scissom
COO, Cover Tenn
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