Clinical Review Manager

Requirements

• 3 years - Clinical experience required
• Skills\Certifications
• 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
• Number of Openings Available
• 1
• Worker Type:
• Employee
• Company:
• BCBST BlueCross BlueShield of Tennessee, Inc.
• Applying for this job indicates your acknowledgement and understanding of the following statements:
• Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
• BCBST's EEO Policies/Notices

Benefits

Additional Information

The Commercial team is hiring a Clinical Review Manager to support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, appeals, and retrospective reviews. The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and supports administrative review processes to ensure compliance with clinical standards and policies. If this opportunity aligns with your experience and interests, we encourage you to apply! What We're Looking For (In Addition to Required Qualifications): Preference for candidates who bring: Strong computer comfort and technical aptitude A collaborative, team‑oriented approach Flexibility and adaptability A positive attitude and willingness to learn Typical Schedule Our team primarily follows a Monday-Friday, 8:00-5:00 schedule with some flexibility. Who You'll Work With This role partners mainly with: Providers and facilities who submit prior authorization requests What Your Day‑to‑Day Looks Like Your daily focus includes: Reviewing cases in strict turnaround‑time order Meeting required deadlines on cases Prioritizing urgent or escalated cases as assigned by leadership Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards Job 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. Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. Job Qualifications 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.

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