Clinical Review Manager

Role Overview

• 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.

Requirements

• 3+ years of experience in a clinical setting (e.g., Case Management, Utilization Management, ICU, Med‑Surg, Oncology, Home Health, or similar)
• Strong clinical judgment with the ability to analyze medical claims and financial data
• Experience reviewing paid and pending claims and understanding drivers of cost and utilization
• Working knowledge of CareAdvance and Agent Workspace
• Confidence presenting to external audiences, with the ability to clearly explain complex clinical and financial concepts
• Active RN License (TN or Compact Status)
• Strong communication and presentation skills
• Exceptional collaboration and customer service mindset

Benefits

• Fully remote role
• Highly collaborative, forward-thinking team
• Values clinical excellence, creativity, and continuous improvement