BCBST BlueCross BlueShield of Tennessee, Inc., is looking for a Clinical Review Manager to support the Blue Advantage Inpatient Utilization Management team. In this RN role, you will ensure members receive appropriate, timely medical care by performing clinical reviews for hospital admissions, injections, and specialty services for adult and senior populations.
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 the 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, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
- Occasional weekend work may be required.
What We're Looking For
- Active RN with a 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.
- Dependable professional with a demonstrated history of stability and long term commitment in prior roles.
- 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 of clinical experience required.
- 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.
Nice to Have
- Excitement around and experience leveraging approved AI tools such as Copilot to drive efficiencies, streamline workflows, and support high quality outcomes.
Technical Stack
- Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Multiple clinical systems
- Windows
Team & Environment
You will join the Blue Advantage Inpatient Utilization Management team.
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.
