Tennessee Licensed Clinical Review Manager

A company is looking for a Clinical Review Manager to oversee medical reviews for utilization management.

Key Responsibilities

Initiate referrals for appropriate coordination of care

Assist in comprehensive provider and member appeals, including denial interpretation and retrospective claim reviews

Collaborate with the Medical Director and non-clinical staff as needed

Required Qualifications

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

Minimum of 3 years of clinical experience

Proficiency in Microsoft Office applications

Working knowledge of URAC, NCQA, and CMS accreditations

Ability to work independently and manage multiple projects