Tennessee Licensed Clinical Review Manager

Job Summary

To support the Commercial lines of business, the full-time Tennessee Licensed Clinical Review Manager will conduct comprehensive clinical reviews of medical service requests, manage utilization activities, and collaborate with medical professionals, all while working remotely.

Key responsibilities

• Conduct comprehensive clinical reviews and manage pre-certifications, appeals, and retrospective reviews
• Initiate referrals and coordinate care while ensuring compliance with clinical standards and policies
• Collaborate with the Medical Director on escalated cases and assist non-clinical staff with administrative reviews

Required qualifications

• Active Registered Nurse (RN) license in Tennessee or a participating state under the Nurse Licensure Compact Law
• Minimum of 3 years of clinical experience
• Proficiency in Microsoft Office Suite (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