Tennessee Licensed Clinical Review Manager

Job Summary

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

Key Responsibilities

• Conduct comprehensive clinical reviews of medical service requests and support utilization management activities
• Collaborate with the Medical Director on escalated cases and facilitate care coordination
• Assist non-clinical staff with administrative reviews and perform provider and member appeals

Required Qualifications

• Active Registered Nurse (RN) license in Tennessee or a participating Nurse Licensure Compact 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 in a fast-paced environment