Tennessee Licensed Clinical Review Manager

Job Summary

Seeking a Tennessee Licensed Clinical Review Manager, this full-time remote position will manage the clinical and financial review of paid and pending claims, translate complex information for stakeholders, and present insights to external audiences.

Key responsibilities

• Initiate referrals to ensure appropriate coordination of care
• Perform comprehensive provider and member appeals, denial interpretation, and retrospective claim reviews
• Present clinical and financial insights to employer groups and consultants

Required qualifications

• Active RN License in Tennessee or Compact Status
• Minimum of 3 years of clinical experience in settings such as Case Management or Utilization Management
• Proficient in Microsoft Office applications
• Working knowledge of URAC, NCQA, and CMS accreditations
• Experience in analyzing medical claims and financial data