Clinical Review Manager FEP

BlueCross BlueShield of Tennessee • Chattanooga, TN

2d • Remote

About The Position

The FEP team is hiring a Clinical Review Nurse to support the Federal Employee Program (FEP) through BlueCross BlueShield of Tennessee. The Federal Employee Program (FEP) with BlueCross BlueShield of Tennessee provides health insurance coverage to eligible federal employees, retirees, and their families, delivering benefits through the nationwide Blue Cross Blue Shield network. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, 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!

Requirements

• License: Active Registered Nurse (RN) license in the state of Tennessee or a compact state participating in the Nurse Licensure Compact (NLC).
• Experience: Minimum of 3 years of clinical experience required.
• 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
• 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

Nice To Haves

• Strong critical thinking and clinical decision-making skills.
• Knowledge of utilization management, appeals, and medical review processes.
• Familiarity with medical coding standards.
• Ability to manage workflows across multiple platforms.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees