Tennessee Licensed Clinical Manager

Job Summary

Providing clinical oversight and quality review, the remote Tennessee Licensed Clinical Manager will manage appeal submissions, oversee audits for coding accuracy, and ensure compliance with CMS standards while working full-time in a salaried position.

Key responsibilities:

• Provide clinical and coding quality oversight of appeal submissions prior to escalation to the CMS Independent Review Entity (IRE)
• Review vendor-prepared appeals for clinical validity, coding accuracy, and compliance with UHC standards
• Collaborate with internal stakeholders to mitigate regulatory and compliance risks related to appeals

Required qualifications:

• Current, unrestricted Registered Nurse (RN) license
• Certified Professional Coder (CPC) or equivalent nationally recognized coding certification
• 4+ years of experience in clinical denial review or appeal preparation on behalf of a payer
• 1+ years of experience with Inpatient facility DRG coding or auditing
• Demonstrated expertise in applying CMS regulations and coding standards (ICD 10 CM/PCS)