Tennessee Licensed Clinical Review Manager

Job Summary

A company is looking for a Clinical Review Manager.

Key Responsibilities

• Initiate referrals to ensure appropriate coordination of care
• Assist non-clinical staff in performance of administrative reviews and manage appeals
• Perform retrospective claim reviews and pre-certifications utilizing medical appropriateness criteria

Required Qualifications

• Registered Nurse (RN) with an active license in Tennessee or a participating Nurse Licensure Compact state
• Minimum of 3 years of clinical experience
• Proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint)
• Working knowledge of URAC, NCQA, and CMS accreditations
• Ability to work independently and manage multiple projects in a fast-paced environment