Clinical Review Manager

BCBST BlueCross BlueShield of Tennessee, Inc.

Tennessee, US
**
Active rn license
Inpatient hospital experience
Apply standardized clinical guidelines
** BCBST BlueCross BlueShield of Tennessee is seeking a Clinical Review Manager, an experienced RN responsible for conducting clinical reviews for hospital admissions and specialty services, with a focus on improving patient outcomes. The ideal candidate will have substantial inpatient nursing experience, strong communication skills, and a commitment to quality care. **

Job Summary

  • 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.
  • Support high quality, medically necessary care while ensuring compliance with UM standards.

Matching Summary

Match Score: 75

** BCBST BlueCross BlueShield of Tennessee is seeking a Clinical Review Manager, an experienced RN responsible for conducting clinical reviews for hospital admissions and specialty services, with a focus on improving patient outcomes. The ideal candidate will have substantial inpatient nursing experience, strong communication skills, and a commitment to quality care. **

Skills & Requirements

Must-have

  • Active RN license
  • Inpatient hospital experience
  • Apply standardized clinical guidelines
  • Review clinical documentation
  • Phone based interactions
  • Leveraging approved AI tools

Nice-to-have

  • Independent and creative manner
  • Customer service oriented
  • Adaptive to high pace
  • Problem-solving skills

Key Requirements

  • Minimum three years clinical nursing experience
  • Active RN license in Tennessee or NLC state
  • Proficient in Microsoft Office Suite
  • Working knowledge of URAC, NCQA, CMS accreditations
  • Ability to interpret benefits and contract language
  • Must pass Windows navigation test

Work Rights

Not specified

Tailored Resume

Cover Letter