Clinical Review Manager
| Company | BlueCross BlueShied of Tennessee |
|---|---|
| Location | Chattanooga, TN, USA |
| Salary | $Not Provided – $Not Provided |
| Type | Full-Time |
| Degrees | Bachelor’s |
| Experience Level | Mid Level |
Requirements
- 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
- 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
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
Preferred Qualifications
- A strong nursing background working a variety of adult care settings is preferred