Clinical Review Manager at Bcbst

Join the BlueCare team at BCBST as a Clinical Review Manager!

In this role, you will complete medical reviews for utilization management within the BlueCare member population.  You’ll have the opportunity to collaborate with the BlueCare Utilization Management team, Case Managers, and other departments.

The ideal candidate for this role is a quick learner who thrives in a role that requires attention to detail and research skills.  The role also requires the ability to navigate clinical information and disseminate it in a timely manner.  Finally, we’re looking for a candidate with strong communication skills to be able to work effectively across multiple teams.

Key Schedule Details:

• Typical schedule is 8-5 pm EST or 9-6 pm EST.
• Fully remote, at home position.
• There is an option, upon management approval, for alternative workdays or a compressed work schedule.
  • For example, the Clinical Review Manager may work five 8-hour shifts or four 10-hour shifts, which may include a combination of weekdays and weekends (e.g., Wednesday–Sunday or Thursday–Sunday)."

Join our team and make a significant impact on the quality of care our members receive!

Job Responsibilities

• Initiate referrals to ensure appropriate coordination of care.
• Seek the advice of the Medical Director when appropriate, according to policy.
• Assists non-clinical staff in performance of administrative reviews
• Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
• Occasional weekend work may be required.
• Must be able to pass Windows navigation test.
• Testing/Assessments will be required for Digital positions.
• Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.

Job Qualifications

License

• Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

• 3 years - Clinical experience required

SkillsCertifications

• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Working knowledge of URAC, NCQA and CMS accreditations
• Must be able to work in an independent and creative manner.
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Ability to manage multiple projects and priorities
• Adaptive to high pace and changing environment
• Customer service oriented
• Superior interpersonal, client relations and problem-solving skills
• Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria

Number of Openings Available

Worker Type:

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Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.