Clinical Review Manager

Clinical Review Manager, Blue Advantage Inpatient UM

The Blue Advantage Inpatient Utilization Management team is seeking an experienced RN to support clinical reviews for hospital admissions, injections, and specialty services for our adult and senior populations. This role is ideal for a nurse with hands on inpatient hospital experience who is passionate about ensuring members receive appropriate, timely medical care. You will play a key role in identifying barriers to care, applying standardized clinical guidelines, and connecting members with resources that improve outcomes.

What You’ll Do

• Review clinical documentation for inpatient admissions, injections, and specialty services for adult members
• Apply standardized clinical guidelines to support utilization management decisions
• Take and manage inbound clinical requests by phone, requiring consistent phone coverage throughout the shift
• Identify barriers to care and connect members, especially seniors, with appropriate resources
• Support high quality, medically necessary care while ensuring compliance with UM standards

Skills We’re Looking For

• Active RN with a minimum of three years of clinical nursing experience
• Inpatient hospital experience with a strong understanding of acute care workflows
• Background working with adult populations across a variety of care settings
• Strong computer skills and comfort navigating multiple clinical systems
• Ability to interpret clinical information and apply it to standardized guidelines
• Clear, professional communication skills for frequent phone based interactions
• Dependable professional with a demonstrated history of stability and long term commitment in prior roles
• Excitement around and experience leveraging approved AI tools such as Copilot to drive efficiencies, streamline workflows, and support high quality outcomes

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

Skills\Certifications

• 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:

Company:

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.