The Commercial team is hiring aClinical Review Managerto support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as precertifications, appeals, and retrospective reviews. The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and supports administrative review processes to ensure compliance with clinical standards and policies. If this opportunity aligns with your experience and interests, we encourage you to apply!

What We27re Looking For (In Addition to Required Qualifications):

Preference for candidates who bring:

• Strongcomputer comfort and technical aptitude

• A collaborative,teamorientedapproach

• Flexibilityand adaptability

• A positive attitude and willingness to learn

Typical Schedule

Our team primarily follows aMonday2DFriday, 8:002D5:00schedule with some flexibility.

Who You27ll Work With

This role partners mainly with:

• Providers and facilitieswho submit prior authorization requests

What Your Day2Dto2DDay Looks Like

Your daily focus includes:

• Reviewing cases in strictturnaround2Dtime order

• Meeting required deadlines on cases

• Prioritizing urgent or escalated cases as assigned by leadership

• Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards

Job 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.

Job Qualifications

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.

Experience

• 3 years - Clinical experience required

Skills\Certifications

• 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

Number of Openings Available

Worker Type:

Company: