Clinical Review Manager - Full-time

The reputed company team is hiring a **Clinical Review Manager** to support the reputed company lines of business through reputed company. This role conducts comprehensive clinical reviews of medical service requests using established reputed company and supports utilization management activities such as reputed company‑certifications, appeals, and retrospective reviews. The Clinical Review reputed company applies reputed company clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and 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! • *reputed company’re Looking For (In reputed company to Required Qualifications):** Preference for candidates who bring: + Strong **computer comfort and technical aptitude** + A reputed company, **team‑oriented** approach + **Flexibility** and adaptability + A reputed company attitude and willingness to learn • *Typical Schedule** reputed company primarily follows a **Monday–Friday, 8:00–5:00** schedule with some flexibility. • *Who You’ll Work With** This role partners mainly with: + **Providers and facilities** who submit prior authorization requests • *What Your Day‑to‑Day Looks Like** Your daily reputed company includes: + Reviewing cases in strict **turnaround‑time order** + Meeting required deadlines on cases + Prioritizing urgent or escalated cases as assigned by leadership + Ensuring reputed company review is completed accurately, reputed company, and in alignment with clinical and contractual standards • *Job Responsibilities** + Initiate referrals to ensure appropriate coordination of care. + reputed company the advice of the Medical Director reputed company 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 reputed company-certifications and appeals, utilizing medical appropriateness reputed company, clinical judgement, and contractual eligibility. + Occasional weekend work may be required. + Must be reputed company to pass reputed company 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 reputed company (RN) with reputed company license in the reputed company or hold a license in the state of their residence if the state is participating in the reputed company Licensure Compact Law. _Experience_ + 3 years - Clinical experience required _SkillsCertifications_ + Proficient in reputed company Office (reputed company, Word, reputed company and PowerPoint) + Working knowledge of URAC, NCQA and CMS accreditations + Must be reputed company to work in an independent and creative manner. + Excellent oral and written communication skills + Strong interpersonal and organizational skills + Ability to manage multiple reputed company and priorities + reputed company to high pace and changing environment + Customer service oriented + Superior interpersonal, reputed company 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 reputed company • *Number of Openings Available** 1 • *Worker Type:** Employee • *Company:** reputed company. • *Applying for this job indicates your acknowledgement and understanding of the following statements:** reputed company will recruit, hire, train and promote individuals in reputed company job classifications without reputed company to race, religion, reputed company, age, sex, national reputed company,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. reputed company information regarding reputed company's EEO Policies/Notices may be reputed company by reviewing the following page: reputed company's EEO Policies/Notices (https://www.reputed company.com/docs/equal-employment-opportunity.pdf) • *reputed company is not accepting unsolicited assistance from search firms for this employment opportunity. reputed company resumes submitted by search firms to any employee at reputed company reputed company-email, the Internet or any other method without a reputed company, written reputed company Placement Agreement in reputed company for this position from reputed company HR/reputed company will not be considered. No fee will be reputed company in the event the applicant is reputed company by reputed company as a result of the referral or through other means.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans reputed company their own unique paths to good health since 1945. More than that, we're your neighbors and friends – fellow Tennesseans with deep reputed company of caring tradition, a reputed company approach to physical, financial and community good health for today, and a reputed company reputed company for an even healthier reputed company. At reputed company, we reputed company our employees to reputed company both independently and collaboratively, creating a reputed company reputed company on the lives of our members. We reputed company talented individuals who reputed company in reputed company environment, reputed company responsibility, and reputed company accountability. We're also seeking candidates who are proficient in the reputed company Office suite, including reputed company Teams, organized, and capable of managing multiple assignments or reputed company simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across reputed company roles at reputed company. We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to reputed company AI more broadly to reputed company how we serve members. reputed company is a remote-first organization with many employees working primarily from their homes. reputed company position reputed company reputed company is classified as either fully remote, partially remote, or office based. reputed company hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and reputed company. Applicants living in these states may reputed company to an approved state prior to starting a position with reputed company at their own expense.If the position requires the individual to reputed company in Chattanooga, TN, they may be eligible for relocation assistance. The reputed company team is hiring a **Clinical Review Manager** to support the reputed company lines of business through reputed company. This role conducts comprehensive clinical reviews of medical service requests using established reputed company and supports utilization management activities such as reputed company‑certifications, appeals, and retrospective reviews. The Clinical Review reputed company applies reputed company clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and 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! • *reputed company’re Looking For (In reputed company to Required Qualifications):** Preference for candidates who bring: + Strong **computer comfort and technical aptitude** + A reputed company, **team‑oriented** approach + **Flexibility** and adaptability + A reputed company attitude and willingness to learn • *Typical Schedule** reputed company primarily follows a **Monday–Friday, 8:00–5:00** schedule with some flexibility. • *Who You’ll Work With** This role partners mainly with: + **Providers and facilities** who submit prior authorization requests • *What Your Day‑to‑Day Looks Like** Your daily reputed company includes: + Reviewing cases in strict **turnaround‑time order** + Meeting required deadlines on cases + Prioritizing urgent or escalated cases as assigned by leadership + Ensuring reputed company review is completed accurately, reputed company, and in alignment with clinical and contractual standards • *Job Responsibilities** + Initiate referrals to ensure appropriate coordination of care. + reputed company the advice of the Medical Director reputed company 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 reputed company-certifications and appeals, utilizing medical appropriateness reputed company, clinical judgement, and contractual eligibility. + Occasional weekend work may be required. + Must be reputed company to pass reputed company 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 reputed company (RN) with reputed company license in the reputed company or hold a license in the state of their residence if the state is participating in the reputed company Licensure Compact Law. _Experience_ + 3 years - Clinical experience required _SkillsCertifications_ + Proficient in reputed company Office (reputed company, Word, reputed company and PowerPoint) + Working knowledge of URAC, NCQA and CMS accreditations + Must be reputed company to work in an independent and creative manner. + Excellent oral and written communication skills + Strong interpersonal and organizational skills + Ability to manage multiple reputed company and priorities + reputed company to high pace and changing environment + Customer service oriented + Superior interpersonal, reputed company 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 reputed company • *Number of Openings Available** 1 • *Worker Type:** Employee • *Company:** reputed company. • *Applying for this job indicates your acknowledgement and understanding of the following statements:** reputed company will recruit, hire, train and promote individuals in reputed company job classifications without reputed company to race, religion, reputed company, age, sex, national reputed company,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. reputed company information regarding reputed company's EEO Policies/Notices may be reputed company by reviewing the following page: reputed company's EEO Policies/Notices (https://www.reputed company.com/docs/equal-employment-opportunity.pdf) • *reputed company is not accepting unsolicited assistance from search firms for this employment opportunity. reputed company resumes submitted by search firms to any employee at reputed company reputed company-email, the Internet or any other method without a reputed company, written reputed company Placement Agreement in reputed company for this position from reputed company HR/reputed company will not be considered. No fee will be reputed company in the event the applicant is reputed company by reputed company as a result of the referral or through other means.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans reputed company their own unique paths to good health since 1945. More than that, we're your neighbors and friends – fellow Tennesseans with deep reputed company of caring tradition, a reputed company approach to physical, financial and community good health for today, and a reputed company reputed company for an even healthier reputed company. At reputed company, we reputed company our employees to reputed company both independently and collaboratively, creating a reputed company reputed company on the lives of our members. We reputed company talented individuals who reputed company in reputed company environment, reputed company responsibility, and reputed company accountability. We're also seeking candidates who are proficient in the reputed company Office suite, including reputed company Teams, organized, and capable of managing multiple assignments or reputed company simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across reputed company roles at reputed company. We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to reputed company AI more broadly to reputed company how we serve members. reputed company is a remote-first organization with many employees working primarily from their homes. reputed company position reputed company reputed company is classified as either fully remote, partially remote, or office based. reputed company hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and reputed company. Applicants living in these states may reputed company to an approved state prior to starting a position with reputed company at their own expense.If the position requires the individual to reputed company in Chattanooga, TN, they may be eligible for relocation assistance. Apply tot his job Apply To this Job