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 the Medical Director while working remotely.

Key responsibilities

• Perform comprehensive reviews of medical service requests, ensuring compliance with clinical standards and contractual guidelines
• Initiate referrals and coordinate care, collaborating with providers and facilities on prior authorization requests
• Assist in the administrative review process, including appeals and retrospective claim reviews, while meeting strict turnaround times

Required qualifications

• Active Registered Nurse (RN) license in Tennessee or participating Nurse Licensure Compact state
• 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