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**Clinical Review Manager** – The BlueAdvantage Inpatient Utilization Management department is looking for an RN with at least 3 years of clinical experience to join our team\. This position reviews clinical for hospital and post\-acute admissions for the adult population\. A strong nursing background working a variety of adult care settings is preferred\.

There are a few shift options for flexibility: The standard work week of M\-F, 8 AM\-5 PM Eastern Time Zone or a compressed work week schedule of four 10\-hour weekday shifts, 7 AM\-6 PM Eastern Time Zone\. The nurse does take requests over the phone which requires constant phone coverage throughout the shift\.

This position assists the senior population by ensuring members receive needed medical care, identifying any barriers to care, and offering resources to eliminate those barriers\. Good computer skills, understanding the clinical information as it applies to standardized guidelines, and great communication are foundations for success in this role\.

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\.

+ 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 Qualifications

_License_

+ 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

BBEX 10 AEP

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 \(https://www\.bcbst\.com/docs/equal\-employment\-opportunity\.pdf\)

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\.

Tobacco\-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products \(including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes\) in any form in Tennessee and where state law permits\. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community\. **All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test\.** An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotineand/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six \(6\) months from the date of the post offer screening results\.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree\.gov or 1\-800\-QUIT\-NOW\.

About Us

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\.

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 applicant moves to Chattanooga, TN, they may be eligible for relocation benefits\.