Clinical Review Manager

Clinical Review Manager

The Outpatient Clinical Review team at BlueCross BlueShield of Tennessee (BCBST) is seeking a highly skilled and motivated Clinical Review Manager to join our exceptional team. This role combines deep clinical expertise with financial and claims analysis, supporting our mission to showcase the value of care management while driving insight, transparency, and innovation.

In this role, you will serve as an expert in the clinical and financial review of paid and pending claims, translating complex information into meaningful insights for both internal partners and external stakeholders. You will regularly present to employer groups, consultants, and other external audiences, helping BCBST shine through clear communication, clinical credibility, and thoughtful analysis. Ideal candidates are energized by finding new and creative ways to elevate care management, demonstrate value, and strengthen partnerships.

You will be a great match for this role if you have:

• 3+ years of experience in a clinical setting (e.g., Case Management, Utilization Management, ICU, Med-Surg, Oncology, Home Health, or similar)
• Strong clinical judgment with the ability to analyze medical claims and financial data
• Experience reviewing paid and pending claims and understanding drivers of cost and utilization
• Working knowledge of CareAdvance and Agent Workspace
• Confidence presenting to external audiences, with the ability to clearly explain complex clinical and financial concepts
• The ability to showcase the value of BlueCross BlueShield of Tennessee's care management team, provider network, and various products through thoughtful analysis and storytelling
• Strong technical competence and comfort working with data, reports, and clinical systems
• A passion for innovation and enthusiasm for elevating care management and the BCBST story
• Interest in applying AI-assisted insights to improve workflows and presentation content

Required Qualifications

• Active RN License (TN or Compact Status)
• Strong communication and presentation skills
• Exceptional collaboration and customer service mindset

Additional Information

• Although we are based in Chattanooga, TN, this is a fully remote role.
• The Clinical Review Manager will join a highly collaborative, forward-thinking team that values clinical excellence, creativity, and continuous improvement.

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

Number of Openings Available

1

Worker Type:

Employee

Company:

VSHP Volunteer State Health Plan, 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.