Clinical Review Manager

BlueCross BlueShield of Tennessee

Clinical Review Manager at BCBST responsible for coordinating care and managing patient appeals. Requires active RN license and 3 years clinical experience.

Posted 5/20/2026full-timeRemote • Tennessee • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

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, and special review requests, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
Occasional weekend work may be required.

Requirements

What you’ll need

License 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

Benefits

Comp & perks

Work from home options
Health insurance
Paid time off for vacations and holidays

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical experiencedenial interpretationretrospective claim reviewmedical appropriateness criteriaclinical judgementcontractual eligibility

Soft Skills

oral communicationwritten communicationinterpersonal skillsorganizational skillsproject managementcustomer service orientation

Certifications

Registered Nurse (RN) license