Tennessee Licensed Clinical Review Manager

Job Summary

To ensure appropriate coordination of care, the full-time Tennessee Licensed Clinical Review Manager will initiate referrals, assist with administrative reviews, and perform comprehensive provider and member appeals while working remotely.

Key responsibilities

• Initiate referrals and coordinate care effectively
• Assist non-clinical staff in administrative reviews and seek Medical Director advice when necessary
• Perform appeals, denial interpretations, and retrospective claim reviews using clinical judgment and medical appropriateness criteria

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 Suite (Outlook, Word, Excel, PowerPoint)
• Knowledge of URAC, NCQA, and CMS accreditations
• Ability to work independently and manage multiple projects in a fast-paced environment