Clinical Review Manager

BlueCross BlueShield of Tennessee • Chattanooga, TN

5d

About The Position

This position involves initiating referrals for care coordination, seeking advice from the Medical Director when necessary, and assisting non-clinical staff with administrative reviews. The role requires performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals. This is done by utilizing medical appropriateness criteria, clinical judgment, and contractual eligibility. Occasional weekend work may be required. Candidates must be able to pass a Windows navigation test, and 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.

Requirements

• 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
• 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
• Must be able to pass Windows navigation test.

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: Mid Level