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 through referrals
• Ensure compliance with clinical standards and policies while meeting required deadlines on cases

Required Qualifications

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