BlueCross BlueShield of Tennessee · 7 hours ago
Clinical Review Manager
United States
Full-time
Remote
Mid Level
3+ years expBlueCross BlueShield of Tennessee is seeking a Clinical Review Manager to support their Commercial lines of business. This role involves conducting comprehensive clinical reviews of medical service requests and supporting utilization management activities, ensuring compliance with clinical standards and policies.
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
Occasional weekend work may be required
Must be able to pass Windows navigation test
Testing/Assessments will be required for Digital positions
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions
Qualification
Required
Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law
3 years - 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 computer comfort and technical aptitude
A collaborative, team-oriented approach
Flexibility and adaptability
A positive attitude and willingness to learn
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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