Tennessee Licensed Clinical Review Manager

Job Summary

A company is looking for a Clinical Review Manager to support the Commercial lines of business.

Key Responsibilities

• Initiate referrals for care coordination and assist with administrative reviews
• Conduct comprehensive provider and member appeals, retrospective claim reviews, and UM pre-certifications
• Collaborate with the Medical Director on escalated cases and ensure compliance with clinical standards

Required Qualifications

• Registered Nurse (RN) with an active license in Tennessee or a participating state
• Minimum of 3 years of clinical experience
• Proficient in Microsoft Office applications
• Working knowledge of URAC, NCQA, and CMS accreditations
• Ability to work independently and manage multiple projects in a fast-paced environment