BlueCross BlueShield of Tennessee seeks an experienced Clinical Review Manager to join the Blue Advantage Inpatient Utilization Management team. This role is designed for an RN with hands-on inpatient hospital experience who is dedicated to ensuring members, particularly adults and seniors, receive appropriate and timely medical care through clinical review.
What You'll Do
- Review clinical documentation for inpatient admissions, injections, and specialty services for adult members
- Apply standardized clinical guidelines to support utilization management decisions
- Take and manage inbound clinical requests by phone, requiring consistent phone coverage throughout your shift
- Identify barriers to care and connect members, especially seniors, with appropriate resources
- Support high-quality, medically necessary care while ensuring compliance with UM standards
- Initiate referrals to ensure appropriate coordination of care
- Seek the advice of the Medical Director when appropriate, according to policy
- Assist non-clinical staff in performance of administrative reviews
- Perform comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals
- Utilize medical appropriateness criteria, clinical judgement, and contractual eligibility in all reviews
- Occasionally work weekends as required
What We're Looking For
- Active Registered Nurse (RN) license in the state of Tennessee or a license in your state of residence if participating in the Nurse Licensure Compact Law
- Minimum of three years of clinical nursing experience
- Inpatient hospital experience with a strong understanding of acute care workflows
- Background working with adult populations across a variety of care settings
- Strong computer skills and comfort navigating multiple clinical systems
- Ability to interpret clinical information and apply it to standardized guidelines
- Clear, professional communication skills for frequent phone-based interactions
- A dependable professional with a demonstrated history of stability and long-term commitment in prior roles
- Excitement around and experience leveraging approved AI tools such as Copilot to drive efficiencies, streamline workflows, and support high-quality outcomes
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Working knowledge of URAC, NCQA and CMS accreditations
- Ability 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, adaptable to a high-paced and changing environment
- Customer service orientation with superior interpersonal, client relations and problem-solving skills
- Proficient in interpreting benefits, contract language (symptom-driven, treatment driven, look back periods, rider information) and medical policy/medical review criteria
- Ability to pass a Windows navigation test
- Willingness to complete required testing/assessments for digital positions
- Commitment to remain in the position for 18 months before posting for other internal positions
Technical Stack
- Microsoft Office Suite (Outlook, Word, Excel, PowerPoint)
- Approved AI tools such as Copilot
Team & Environment
You will be a key member of the Blue Advantage Inpatient Utilization Management team, focused on clinical review operations.
BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.
