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    Clinical Review Manager Utilization Management Clinical Review Manager Utilization Management - Chattanooga, United States - TalentBurst

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    Freelance
    Description
    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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