[Hiring] Clinical Review Manager @BlueCross BlueShield of Tennessee

Role Description

The Commercial team is hiring a Clinical Review Manager to support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, appeals, and retrospective reviews.

• The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care.
• Collaborates with the Medical Director on escalated cases.
• Facilitates care coordination through referrals.
• Supports administrative review processes to ensure compliance with clinical standards and policies.

If this opportunity aligns with your experience and interests, we encourage you to apply!

Qualifications

• 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.
• 3 years of clinical experience required.
• 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.

Requirements

• 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.

Company Description

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.