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Clinical Review Manager
BlueCross BlueShield of TennesseeClinical Review Manager conducting comprehensive clinical reviews of medical requests for BlueCross BlueShield of Tennessee. Supporting utilization management activities and ensuring compliance with clinical standards.
About the role
Key responsibilities & impact- Conduct comprehensive clinical reviews of medical service requests using established criteria
- Support utilization management activities such as pre‑certifications, appeals, and retrospective reviews
- Apply sound clinical judgment and contractual guidelines to promote appropriate care
- Collaborate with the Medical Director on escalated cases
- Facilitate care coordination through referrals
- Support administrative review processes to ensure compliance with clinical standards and policies
- Initiate referrals to ensure appropriate coordination of care
- Seek the advice of the Medical Director when appropriate, according to policy.
- Assist non-clinical staff in performance of administrative reviews
- Perform comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals.
Requirements
What you’ll need- 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
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Ability to manage multiple projects and priorities
- Customer service oriented
- Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria.
Benefits
Comp & perks- Flexible working arrangements
- Professional development opportunities
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewsutilization managementpre-certificationsappealsretrospective reviewsclinical judgmentcare coordinationprovider appealsdenial interpretationmedical policy criteria
Soft Skills
oral communicationwritten communicationinterpersonal skillsorganizational skillsproject managementcustomer service orientation
Certifications
Registered Nurse (RN) license