Clinical Review Manager

BlueCross BlueShield of Tennessee • Chattanooga, TN

6d

About The Position

Join our team as a Clinical Review Manager! We are seeking a quick learner who is self-motivated and capable of working independently. The ideal candidate will be able to efficiently navigate and disseminate clinical information in a timely manner. Proficiency in Microsoft products (Word, Excel, Outlook, Teams) and the ability to function in multiple applications simultaneously are essential. Responsibilities : Research clinical information received from providers using CMS guidelines (LCDs/NCDs, Internet Only Manuals, MCG platform) to ensure members receive the appropriate services necessary to meet their medical needs. Key Details : Fast-paced environment with high case volume. Team members take incoming provider calls daily from 9 AM-6 PM EST. Join our team and make a significant impact on the quality of care our members receive!

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.
• 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.

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
• Education Level: No Education Listed