Clinical Review Manager

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Perform thorough clinical evaluations of medical service requests based on established criteria.

• Assist in utilization management functions, including pre-certifications, appeals, and retrospective reviews.

• Utilize sound clinical judgment and contractual guidelines to encourage appropriate care delivery.

• Work in collaboration with the Medical Director on escalated cases.

• Promote care coordination through effective referrals.

• Aid in administrative review processes to ensure adherence to clinical standards and policies.

• Review cases in strict adherence to turnaround-time requirements.

• Adhere to deadlines for case reviews.

• Prioritize urgent or escalated cases as designated by leadership.

• Initiate referrals to guarantee proper care coordination.

• Consult with the Medical Director when necessary, in accordance with policy.

• Support non-clinical staff in carrying out administrative reviews.

• Conduct comprehensive provider and member appeals, interpret denial letters, perform retrospective claim reviews, and manage special review requests and UM pre-certifications and appeals, using medical appropriateness criteria, clinical judgment, and contractual eligibility.

• Weekend work may be required occasionally.

• Must successfully complete a Windows navigation test. Testing/assessments will be necessary for digital roles.

• Effective from 7/22/13: This position necessitates an 18-month commitment before applying for other internal roles.

⛳️ Requirements

• Active Registered Nurse (RN) license in the state of Tennessee or a license in the resident state if it participates in the Nurse Licensure Compact Law.

• Minimum of 3 years of clinical experience required.

• Proficient in Microsoft Office applications (Outlook, Word, Excel, and PowerPoint).

• Familiarity with URAC, NCQA, and CMS accreditations.

• Ability to work independently and creatively.

• Excellent oral and written communication abilities.

• Strong interpersonal and organizational skills.

• Capability to manage multiple projects and competing priorities.

• Adaptable to a fast-paced and changing environment.

• Customer service-oriented approach.

• Exceptional interpersonal, client relations, and problem-solving skills.

• Skilled in interpreting benefits and contractual language, particularly regarding symptom-driven, treatment-driven, look-back periods, rider information, and medical policy/medical review criteria.

🏝️ Benefits

• N/A