Clinical Review Manager Utilization Management Clinical Review Manager Utilization Management

3 weeks ago


Chattanooga, Tennessee, United States TalentBurst Full time
Clinical Review Manager
Remote
6 Months+

Job Description Summary:
Perform comprehensive clinical review of requested services utilizing clinical criteria, received through various mechanisms.

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 reviews
  • Performing 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.
  • Weekend work required as needed.
  • Must be able to pass Windows navigation test.
  • Testing/Assessments will be required for Digital positions.
    Job Qualifications
    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 accreditations
    • Must be able to work in an independent and creative manner.
    • Excellent oral and written communication skills
    • Strong interpersonal and organizational skills
    • Ability to manage multiple projects and priorities
    • Adaptive to high pace and changing environment
    • Customer service oriented
    • Superior interpersonal, client 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 criteria #TB_HC

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