Clinical Review Manager - LPN

Job Responsibilities + Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures.+ Perform structured clinical reviews (e.g., precertification support, retrospective claim review preparation, and appeal packet preparation) using preset criteria and templates, escalating any findings that require RN/Medical Director interpretation.+ Consult with supervising RN or Medical Director when requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment, consistent with the LPNu2019s directed scope of practice.+ Assist nonclinical staff by clarifying clinical documentation, interpreting request elements within LPN practice parameters, and ensuring accurate case setup for RN/MD decision-making.+ Apply approved medical appropriateness criteria and contractual eligibility information solely to support intake validation and preparation of clinical review materials, without independently determining medical necessity, denying, reducing, terminating services, or issuing adverse determinations.+ Document all review activities in required UM systems with accuracy, completeness, and adherence to regulatory (NCQA/URAC/CMS) documentation standards.+ Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status, using approved scripts and escalation pathways.+ Participate in quality improvement, compliance activities, and competency requirements tied to UM program standards. Job Qualifications License + Licensed Practical Nurse (LPN) 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 + 1-2 years - Clinical experience required SkillsCertifications + Knowledge of community resources, benefits, and service authorization processes.+ Familiarity with care management frameworks and regulatory requirements.+ High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS). This job description is not intended to expand the scope of practice of a Licensed Practical Nurse beyond applicable state licensure laws or to confer independent clinical authority reserved to Registered Nurses or physicians. Number of Openings Available 1 Worker Type: Employee Company: 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 u2013 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 u2014 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: 2026-04-01