Clinical Review Manager

BlueCross BlueShield of Tennessee; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading health insurance provider is seeking a Clinical Review Manager to join their team. The role involves ensuring appropriate clinical services for members, reviewing provider information, and maintaining high standards of care coordination. The ideal candidate will have a strong clinical background, excellent communication skills, and proficiency in navigating various applications in a fast-paced environment. This position requires a commitment to quality care and adherence to regulatory standards.

Qualifications

• Must hold an active RN license in Tennessee or participating NLC state.
• 3 years of clinical experience required.
• Proficiency in Microsoft Office applications is essential.

Responsibilities

• Research clinical information to ensure appropriate member services.
• Initiate referrals for care coordination.
• Assist with administrative reviews and appeals.

Skills

Communication

Interpersonal skills

Organizational skills

Customer service

Time management

Problem-solving

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Join our team as a Clinical Review Manager!

We are seeking a quick learner who is self-motivated and capable of working independently. The ideal candidate will be able to efficiently navigate and disseminate clinical information in a timely manner. Proficiency in Microsoft products (Word, Excel, Outlook, Teams) and the ability to function in multiple applications simultaneously are essential.

Responsibilities:

• Research clinical information received from providers using CMS guidelines (LCDs/NCDs, Internet Only Manuals, MCG platform) to ensure members receive the appropriate services necessary to meet their medical needs.

Key Details:

• Fast-paced environment with high case volume.
• Team members take incoming provider calls daily from 9 AM-6 PM EST.

Join our team and make a significant impact on the quality of care our members receive!

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.

Experience

• 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:

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.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.