Clinical Review Manager – LPN
BlueCross BlueShield of Tennessee
full-time
Posted on:
Location Type: Remote
Location: Tennessee • United States
Visit company websiteExplore more
About the role
- Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures.
- Perform structured clinical reviews using preset criteria and templates, escalating any findings requiring RN/Medical Director interpretation.
- Consult with supervising RN or Medical Director when requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment.
- Assist nonclinical staff by clarifying clinical documentation, interpreting request elements within LPN practice parameters.
- Apply approved medical appropriateness criteria and contractual eligibility information to support intake validation and preparation of clinical review materials.
- Document all review activities in required UM systems with accuracy, completeness, and adherence to regulatory documentation standards.
- Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status.
- Participate in quality improvement, compliance activities, and competency requirements tied to UM program standards.
Requirements
- Licensed Practical Nurse (LPN) 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.
- 1-2 years - Clinical experience required.
- Knowledge of community resources, benefits, and service authorization processes.
- Familiarity with care management frameworks and regulatory requirements.
- High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS).
Benefits
- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
- Remote work options
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewsmedical appropriateness criteriadocumentation standardscare coordination workflowsintake validationclinical judgmentservice authorization processesregulatory requirementscommunity resourcesquality improvement
Soft Skills
attention to detailcommunicationcollaborationinterpretationsupportclarification
Certifications
Licensed Practical Nurse (LPN)