Tennessee Licensed Clinical Review Manager

A company is looking for a Clinical Review Manager to oversee clinical information and ensure appropriate care for members.

Key Responsibilities

Research clinical information from providers using CMS guidelines to ensure members receive necessary services

Initiate referrals and coordinate care while consulting with the Medical Director as needed

Assist with administrative reviews and perform comprehensive appeals and claim reviews

Required Qualifications

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

Minimum of 3 years of clinical experience

Proficiency in Microsoft Office (Outlook, Word, Excel, PowerPoint)

Knowledge of URAC, NCQA, and CMS accreditations

Ability to work independently in a fast-paced environment