Tennessee Licensed Clinical Review Manager

Job Summary

A company is looking for a Clinical Review Manager to oversee medical reviews for utilization management.

Key Responsibilities

• Initiate referrals for appropriate coordination of care
• Assist in comprehensive provider and member appeals, including denial interpretation and retrospective claim reviews
• Collaborate with the Medical Director and non-clinical staff as needed

Required Qualifications

• Active Registered Nurse (RN) license in Tennessee or a participating state
• Minimum of 3 years of clinical experience
• Proficiency in Microsoft Office applications
• Working knowledge of URAC, NCQA, and CMS accreditations
• Ability to work independently and manage multiple projects