BCBST BlueCross BlueShield of Tennessee, Inc. is seeking a Clinical Review Manager to support our Commercial lines of business. In this role, you will perform comprehensive clinical reviews of medical service requests, applying sound clinical judgment and guidelines to promote appropriate care and coordinate with medical leadership.
What You'll Do
- Conduct comprehensive clinical reviews of medical service requests using established criteria.
- Support utilization management activities such as pre-certifications, appeals, and retrospective reviews.
- Apply sound clinical judgment and contractual guidelines to promote appropriate care.
- Collaborate with the Medical Director on escalated cases.
- Facilitate care coordination through referrals.
- Support administrative review processes to ensure compliance with clinical standards and policies.
- 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.
- Review cases in strict turnaround-time order and meet required deadlines.
- Prioritize urgent or escalated cases as assigned by leadership.
- Ensure each review is completed accurately, efficiently, and in alignment with clinical and contractual standards.
What We're Looking For
- Registered Nurse (RN) with an 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.
- Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.
Nice to Have
- Strong computer comfort and technical aptitude.
- A collaborative, team-oriented approach.
- Flexibility and adaptability.
- A positive attitude and willingness to learn.
Technical Stack
- Microsoft Office (Outlook, Word, Excel, PowerPoint)
- Windows
Team & Environment
Partners mainly with providers and facilities who submit prior authorization requests.
Work Mode
This role follows a hybrid work model.
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.
