Clinical Review Manager

Role Overview

• 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
• Start referrals to ensure appropriate coordination of care
• 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
• Meet required deadlines on cases
• Prioritize urgent or escalated cases as assigned by leadership
• Ensure each review is completed accurately, efficiently, and in alignment with clinical and contractual standards

Requirements

• 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
• 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

Benefits

• Occasional weekend work may be required
• Must be able to pass Windows navigation test
• Testing/Assessments will be required for Digital positions