Clinical Review Manager

🔥 22 hours ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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BlueCross BlueShield of Tennessee

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1952

⚕️ Healthcare Insurance

Healthcare Insurance

BlueCross BlueShield of Tennessee is a leading health plan provider in Tennessee, serving 3. 4 million members. The company is committed to creating a workforce where everyone is valued, respected, and part of the team, emphasizing diversity and inclusion. They offer a range of career opportunities, including internships through their BlueBridge program, enabling new professionals to transition from college to work. BlueCross BlueShield of Tennessee also focuses on providing exceptional customer service and community care, striving to make a difference in the healthcare industry. It is an independent licensee of the Blue Cross Blue Shield Association and a qualified health plan issuer in the Health Insurance Marketplace.

📋 Description

• 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.

🎯 Requirements

• 3+ years of experience in a clinical setting (e.g., Case Management, Utilization Management, ICU, Med‑Surg, Oncology, Home Health, or similar) • Strong clinical judgment with the ability to analyze medical claims and financial data • Experience reviewing paid and pending claims and understanding drivers of cost and utilization • Working knowledge of CareAdvance and Agent Workspace • Confidence presenting to external audiences, with the ability to clearly explain complex clinical and financial concepts • Active RN License (TN or Compact Status) • Strong communication and presentation skills • Exceptional collaboration and customer service mindset

🏖️ Benefits

• Fully remote role • Highly collaborative, forward-thinking team • Values clinical excellence, creativity, and continuous improvement