Clinical Review Manager

The Commercial team is hiring a Clinical Review Manager to support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre-certifications, appeals, and retrospective reviews. The Clinical Review Nurse applies sound 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!What We're Looking For (In Addition to Required Qualifications):Preference for candidates who bring: Strong computer comfort and technical aptitudeA collaborative, team-oriented approachFlexibility and adaptabilityA positive attitude and willingness to learn Typical ScheduleOur team primarily follows a Monday-Friday, 8:00-5:00 schedule with some flexibility.Who You'll Work WithThis role partners mainly with: Providers and facilities who submit prior authorization requests What Your Day-to-Day Looks LikeYour daily focus includes: Reviewing cases in strict turnaround-time order Meeting required deadlines on cases Prioritizing urgent or escalated cases as assigned by leadership Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards Job Responsibilities Initiate referrals to ensure appropriate coordination of care.Seek the advice of the Medical Director when appropriate, according to policy.Assists non-clinical staff in performance of administrative reviewsPerforming comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.Occasional weekend work may be required.Must be able to pass Windows 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 QualificationsLicense Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law. Experience 3 years - Clinical experience required Skills/Certifications Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)Working knowledge of URAC, NCQA and CMS accreditationsMust be able to work in an independent and creative manner.Excellent oral and written communication skillsStrong interpersonal and organizational skillsAbility to manage multiple projects and prioritiesAdaptive to high pace and changing environmentCustomer service orientedSuperior interpersonal, client relations and problem-solving skillsProficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria Number of Openings Available1Worker Type:EmployeeCompany:BCBST BlueCross BlueShield of Tennessee, Inc.Applying for this job indicates your acknowledgement and understanding of the following statements:BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:BCBST's EEO Policies/Notices (BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability.We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST.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 leverage AI more broadly to transform how we serve members.BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based.BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.

Created: 2026-03-04