Tennessee Licensed Clinical Review Manager

To ensure appropriate coordination of care, the full-time Tennessee Licensed Clinical Review Manager will initiate referrals, assist with administrative reviews, and perform comprehensive provider and member appeals while working remotely. Key responsibilities Initiate referrals and coordinate care effectively Assist non-clinical staff in administrative reviews and seek Medical Director advice when necessary Perform appeals, denial interpretations, and retrospective claim reviews using clinical judgment and medical appropriateness criteria Required qualifications Active Registered Nurse (RN) license in Tennessee or a participating Nurse Licensure Compact state Minimum of 3 years of clinical experience Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint) Knowledge of URAC, NCQA, and CMS accreditations Ability to work independently and manage multiple projects in a fast-paced environment